Diverticular Disease:Emerging Evidencein a CommonCondition

June 17–18, 2005Munich /Germany

PreliminaryAbstractsPoster Abstracts

Falk Symposium 148

Munich

Abstracts of Invited Lectures Poster Abstracts

Falk Symposium 148

DIVERTICULAR DISEASE:EMERGING EVIDENCEIN A COMMON CONDITION

Munich (Germany)June 17 - 18, 2005

Scientific Organization:A. Forbes, Harrow (UK)K.-W. Jauch, Munich (Germany)W. Kruis, Cologne (Germany)S.D. Wexner, Weston (USA)

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CONTENTS

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Session I

Pathogenesis of diverticular disease 13

Chair:B. Göke, MunichA. Revhaug, Tromsö

Patterns of mucosal inflammation in diverticular diseaseN.Y. Haboubi, Manchester 15

Enteric neuropathyT. Wedel, Lübeck 16

Altered motilityM. Kreis, Munich 17

Genetic disposition versus the environmentA. Forbes, Harrow 18

Session II

Clinical issues 19

Chair:M. Anthuber, AugsburgM. Lukas, Prague

Definition(s) for diverticular diseaseE. Neugebauer, Cologne 21 - 22

Left-sided and right-sided diverticular disease -two entities? (no abstract)R. Cohen, Harrow

Prognosis of acute diverticulitisS. Hollerbach, Celle 23

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Session III

Diagnosis I 25

Chair:H. Koop, BerlinH. Zirngibl, Wuppertal

Primary diagnostic work-up in outpatients (no abstract)R. Jones, London

Diagnosis in emergency cases (no abstract)J.M. Müller, Berlin

Laboratory tests - what do they tell us?C. Gasché, Vienna 27

Lower gastrointestinal bleeding -search for sourcesJ. Schölmerich, Regensburg 28

Session IV

Diagnosis II 29

Chair:M. Cainzos, Santiago de CompostellaP. Layer, Hamburg

Intestinal comorbidityH. Krammer, Mannheim 31

Symptoms in patients with diverticula -always diverticular disease?L.M.A. Akkermans, Utrecht, M. Ekelund, Lund 32

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Session V

Indications and controversies in imagingtechniques (round table) 33

Chair:P. Marteau, ParisS. Post, Mannheim

Colonoscopy in acute diverticulitisS. Bar-Meir, Tel Hashomer 35

Diverticular disease: Diagnostic value of ultrasoundS. Schanz, Cologne 36

Diverticular disease: Diverticulitis -Contrast enema, CT, MRTS. Feuerbach, Regensburg 37 - 38

Session VI

Determinants of treatment 39

Chair:C. Hüscher, RomeM. Zeitz, Berlin

Natural course of the diseaseM.Z. Panos, Athens 41

Mechanisms of pain in diverticular diseaseR.C. Spiller, Nottingham 42

Extraintestinal comorbidity (no abstract)B. Lembcke, Gladbeck

Outcome measuresJ.C. Hoffmann, Berlin 43 - 44

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Session VII

Surgery 45

Chair:W.E. Fleig, HalleS.D. Wexner, Weston

Principles of surgical strategyN. Senninger, Münster 47 - 48

Extent of sigmoid resectionA. Fingerhut, Poissy 49

Controversy: Laparoscopic surgery

Pro: (no abstract)A. Lacy, Barcelona

Laparoscopic surgery - still controversial?V. Schumpelick, M. Stumpf, S. Willis, Aachen 50 - 51

Session VIII

Medical treatment 53

Chair:E.M.M. Quigley, CorkM. Starlinger, Klagenfurt

Bulking agents as a therapy for diverticular disease:Fact or fictionJ. Lindsay, London 55

Antibiotics in the treatment of diverticular diseaseof the colonG. Latella, L’Aquila 56 - 57

ProbioticsP. Gionchetti, Bologna 58

AminosalicylatesV. Gross, Amberg 59 - 60

Analgesics/spasmolyticsH. Mönnikes, Berlin 61 - 63

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Session IX

Treatment - miscellaneous 65

Chair:J. Mössner, LeipzigD. Örtli, Basel

Combined surgery for diverticular disease andcomorbidityH.P. Bruch, Lübeck 67

Treatment in non-complicateddiverticular disease (panel discussion)

Risk of surgery (no abstract)J. Jeekel, Rotterdam

Diverticular disease: Persistent symptoms after surgeryM.K. Peter, D. Candinas, B. Egger, Bern 68

Primary and secondary prevention ofdiverticular diseaseW.H. Aldoori, Mississauga 69

Conclusion: The right time for medical - for surgical treatment (no abstract)D. Meyer, Würzburg

List of Speakers, Moderators and Scientific Organizers 71 - 75

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Poster Abstracts

1. Anorectal manometry in patients with left-sided diverticulosisK. Blachut, R. Kempinski, E. Poniewierka (Wroclaw, PL)

2. Colonic diverticulosis. Review of 435 cases from Lower Silesia in PolandK. Blachut, L. Paradowski (Wroclaw, PL)

3. Immediate colonoscopy followed by therapeutic barium enema as highlyeffective and inexpensive management option for diverticular bleedingU. Blaut, J. Marecik, J. Gniady, J. Ejma-Multanski (Cracow, PL)

4. Perforated diverticulitis: Primary or secondary anastomosis?C. Elsing, M. Zivec, W. Gross-Weege (Dorsten, D)

5. Is colonic diverticulosis a risk factor for colorectal tumors?O. Fratila, A. Lenghel, A. Maghiar (Oradea, RO)

6. Escherichia coli Nissle 1917 (ECN) prolongs remission in symptomaticuncomplicated diverticular disease of the colonP. Fric, M. Zavoral (Prague, CZ)

7. Urgent surgery for complicated colonic diverticulaG. Funariu, V. Bintintan, R. Seicean (Cluj-Napoca, RO)

8. Experience of treatment of diverticulitisI. Gaponov, V.V. Gaponov, Z.I. Shevtsova (Dnepropetrovsk, UKR)

9. Peculiarities of forming of diverticulas in experiment and treating of diverticulardisease in clinicV.V. Gaponov, I. Gaponov, Z.I. Shevtsova (Dnepropetrovsk, UKR)

10. Malabsorption syndrome in jejunal diverticulosisV. Gerova, S. Stoinov, H. Kadyan, E. Piriova (Sofia, BG)

11. Incidence of colonic diverticulosis in patients with significant symptoms of lowergastrointestinal tract diseaseJ. Gniady, J. Marecik, U. Blaut, J. Ejma-Multanski (Cracow, PL)

12. Are nonsteroidal anti-inflammatory drugs (NSAID) and Aspirin a risk factor fordiverticular bleeding?A. Goldis, V. Lungu, R. Goldis, C. Vernic, D. Lazar (Timisoara, RO)

13. Treatment of acute complicated diverticulitis - Hartmann's procedure can bereduced to less than 50 %!T. Herzog, U. Mittelkötter, D. Weyhe, C. Müller, W.H. Uhl (Bochum, D)

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14. Silent bowel perforation during colonoscopy in patients with extensive left-sideddiverticular diseaseJ.A. Karagiannis, N. Mathou, K.D. Paraskeva (Athens, GR)

15. The operative procedure has no influence on long-term quality of life afterlaparoscopic and open sigmoid resection - A matched-pairs analysisM.S. Kasparek, E. Schiele, G. Seitz, A. Königsrainer, M. Kreis (Tübingen, Munich, D)

16. Our strategy for treatment of diverticular disease and perforation complications(1982-2004)Z. Kincses, P. Bodrogi, I. Bartha (Debrecen, H)

17. The safety of resection and primary anastomosis in perforated diverticulardiseaseJ.S.W. Lind, C. Bicknell, M. Petrou, D. Owen, N. Tomns, R. Harrison, I.Mitchell, C. Elton, P. Mathur (London, GB)

18. Timing and outcome of surgery in diverticular diseaseD. Mercut, G. Ianosi, D. Neagoe, F. Racanel, M. Calbureanu Popesu, V. Toma(Craiova, RO)

19. Clinical course and outcome of conservative treatment in patients withdiverticulitis of the sigmoid colonM.H. Müller, J. Glatzle, M.S. Kasparek, M. Kreis (Munich, Tübingen, D)

20. Differential or comorbidity diagnosis - A case reportO.P. Petrascu, A.B. Boicean, M.D. Deac, A.C. Coman (Sibiu, RO)

21. Surgical therapy for right-sided diverticular disease: Results of a prospectivestudyO. Schwandner, P. Hildebrand, S. Farke, H.-P. Bruch (Lübeck, D)

22. Laparoscopic colectomy for diverticulitis is not associated with increasedmorbidity when compared to non-diverticular diseaseO. Schwandner, S. Farke, H.-P. Bruch (Lübeck, D)

23. Cyclic rifaximin treatment in uncomplicated colonic diverticular disease -Results of an open studyL. Simon, A. Salamon (Szekszard, H)

24. Colon diverticulitis after kidney transplantationL. Szabó, R. Fedor, Z. Kincses, L. Asztalos (Debrecen, H)

25. Changing indications for surgery in cases of uncomplicated diverticular diseaseR. Szlávik, O. Miskolci, J. Weltner, P. Kupcsulik (Budapest, H)

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26. Diverticulosis coexisting with other pathologic changes in colonM. Szura, A. Matyja, R. Solecki, U. Blaut, J. Kekus (Cracow, PL)

27. Occult lower gastrointestinal bleeding in diverticular diseaseG. Vosskamp, S. Schanz, G. Müller, W. Kruis (Cologne, D)

28. Mercury - a candidate neurotoxin in the pathogenesis of diverticular diseaseM. Golder, L. Ghali, B. Martins, M. Hansson, D.E. Burleigh, P.J. Lunniss, (London, Wales, GB, Stockholm, S)

29. Diverticulitis of the sigmoid colon: Trends in surgical management in a Germanuniversity hospitalC. Ketscher, T. Strauss, P. Hornung, K.W. Jauch, M.E. Kreis (Munich, D)

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Session I

Pathogenesis of diverticular disease

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Patterns of mucosal inflammation in diverticular disease

Professor N.Y. HaboubiTrafford General Hospital, Manchester, UK

This presentation addresses only the mucosal changes in diverticular disease in thesigmoid colon without discussing the pathology of inflammation in the pouch.Diverticular colitis is the preferred terminology for such a condition, which also hasother synonyms like segmental, crescentic and sigmoid colitis. The best definitionwas given by Ludman and Shepherd, which states that "an inflammatory change assuggested colonoscopically and histologically of the luminal part of the sigmoidcolon, affected by diverticular disease". This is irrelevant of the presence or absenceof diverticulitis.The condition may affect up to 25% of cases of sigmoid resection for diverticulardisease.It is important to realise that only a few of these cases have been diagnosed prior tothe resection and hence the problem of accepting it as an entity on its own iscontroversial.The clinical presentation varies significantly. It may last for days to several years.The commonest presentations are bleeding, change of bowel habit and abdominalpain. The less common clinical features include weight loss, vomiting, flactulenceand tenesmus. None of these clinical features are pathognomic to the disease.Radiologically there is no specific feature apart from the presence of diverticulardisease or with the so-called pre-diverticular muscular thickening. Endoscopically,the features are variable, but usually there is a crescentic fold which shows milderythema to florid active inflammation with swollen red patches and congestion.

Pathology

There are three types:

I. The ulcerative colitis like changes: This is characterised by the presence of mild tomoderate crypt distortion with Paneth cell metaplasia, active inflammation and someother crypt changes with sometimes villiform configuration. Invariably there is rectalsparing and therefore the diagnosis of ulcerative colitis should not be entertainedunless there is good topographic mapping-out of the biopsies from various areascoupled with the full clinical information.

II. Crohn's disease like changes: Papers from Burrows and Dixon in the 90s foundthat patients with diverticular disease may have granulomatous type lesionsassociated with focal inflammation and features very similar to Crohn's disease. Theliterature, however, is conflicting regarding fissuring ulceration.

III. Mucosal herniation type: Prominent mucosal fold is seen in up to 90% ofdiverticular disease and in about 10% of those there are prolapsed mucosa andsometimes there is proliferation of the muscular layer giving it the term ofinflammatory myoglandular polyp. Rarely the superficial part of the polyp getsulcerated to produce the so-called cap polyp.

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Pathogenesis of diverticular disease: Enteric neuropathy

Thilo WedelDepartment of Anatomy, University of Lübeck, Germany

Inspite of the clinical and socioeconomical impact the pathogenesis of diverticulardisease is still not completely resolved and considered to be multifactorial. The mostwidely accepted pathogenetic concepts involve ageing, dietary habits, and structuralas well as functional alterations of the colonic wall. Manometric and myoelectricrecordings have shown that disturbances of large bowel motility (e.g. raisedintraluminal pressure, increased motor activity) play a major role in the developmentof diverticula.

Although the enteric nervous system is the key-regulator of normal intestinal motility,studies on intestinal innervation disorders in diverticular disease are scarce.However, recent histopathologic evaluations could demonstrate structural alterationsof intramural ganglia in patients with diverticular disease consisting in an overallincrease in neural tissue and a decrease in the number of nerve cells. Moreover,several enteric neurotransmitters (e.g. vasoactive intestinal polypeptide, substanceP, neuropeptide K, galanin) have been shown to be upregulated in diverticulardisease.

Further evidence for an enteric neuropathy is derived from in-vitro studies of smoothmuscle strips obtained from patients with diverticular disease showing uncoordinatedmuscle contraction, a lesser ability to relax in response to inhibitoryneurotransmitters and an hypersensitivity to acetylcholine due to a compensatoryupregulation of muscarinergic receptors.

It is concluded from these morphological and functional data that alterations of theenteric nervous system may contribute to both the development of diverticula bytriggering intestinal motor dysfunctions and the generation of symptoms possibly bymediating a visceral hypersensitivity due to post-inflammatory neural damage.Furthermore, the overlap of symptoms and physiological abnormalities betweendiverticular disease and irritable bowel syndrome suggests commonpathophysiological effector mechanisms. Although the heterogeneity of theseconditions makes it difficult to encircle the pathogenesis to one single factor, a moredetailed analysis of the underlying enteric neuropathy may open new perspectivesfor more targeted therapeutic approaches.

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Pathogenesis of diverticular disease: Altered motility

M. KreisLudwig-Maximilians University, Hospital Grosshadern, Munich, Germany

The pathophysiology of diverticular disease is poorly understood. The environment,limited exercise, genetic disposition, diet, age and lifestyle potentially contribute tothe development of diverticula. Nevertheless, the underlying pathophysiology thatfinally leads to this morphological alteration of the colonic wall is unclear. Onehypothesis is that diverticula develop secondary to alterations of colonic motility.Here, we present and review the available evidence and arguments supporting thisconcept.

Manometry investigations of the sigmoid colon demonstrated that pressuresrecorded in the lumen are generally higher in patients with diverticula compared tocontrols both before and after a meal, occasionally exceeding 300 cmH2O (Trotman1988). In more detailed investigations, Bassotti et al. (2001) found furthermore thatthe pattern of colonic motility is altered in patients with diverticular disease displayingan increase of forceful propulsive activity compared to control subjects. In 20 percentof such activity this propagated motility was directed in a retrograde direction.Compared to controls, patients with diverticulosis had prolonged periods of phasicpressure activity (Bassotti 2005). Interestingly, this group reported that periods ofphasic pressure activity were associated with crampy abdominal pain.

The concept that altered motility is associated and - potentially - generates thedevelopment of diverticula is further supported by some intriguing aspects. First, theprevalence of this disorder increases with age (Almy 1980). This is paralleled byobservations of colonic motility showing that segmental contractile activity alsoincreases with age (DiLorenzo 1995) which may be related to aging of colonicsmooth muscle (Butt 1993). Second, Cortesini (1991) reported patients withsymptomatic diverticular disease to display a higher colonic motility index duringmanometry when compared to patients carrying diverticula without symptoms. Third,the abnormal motility was reduced following surgery (Cortesini 1989).In conclusion, there is evidence that symptomatic diverticular disease is associatedwith increased pressure peaks in the colon, prolonged periods of elevatedintraluminal pressure and altered patterns of colonic motility. It remains to bedetermined, however, whether these alterations in colonic motility are causing thelater development of colonic diverticula or whether they are rather secondary tostructural changes in the colonic wall subsequent to diverticular disease.

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Pathogenesis of diverticular disease: Genetic dispositionversus the environment

Alastair ForbesSt Mark's Hospital and Academic Institute, London, UK

Diverticulosis affects more than 50% of those aged over 60 in Western populations.During much of the latter part of the 20th century it was attributed to low fibre dietsand to the prolonged colonic transit time and increased intraluminal pressureassociated with low volume stools. It is not clear that low fibre is the full explanation,and family studies have indicated a genetic component to the risk of developing thecondition. However, it must be conceded that the literature is thin indeed.There have been isolated reports describing the condition affecting multiple siblingsincluding monozygotic twins, and at unusually young ages. Three affected youngadult siblings of a Nigerian family are especially interesting as they reflect apopulation group in whom the condition is normally rare (if increasingly prevalent).However, the three siblings had spent some years in the more industrialized worldand environmental factors are not excluded. There do not appear to be any formalepidemiological family studies that would permit a more confident interpretation.

It has been suggested that colonic diverticulosis is associated with other conditionsknown to be inherited, and in particular with the polycystic kidney syndromes. It doesnot appear that there is a link with the polycystic gene defect carried on chromosome4, but it is possible that the polycystic gene on the short arm of chromosome 16 isimportant. Following initially reported prevalences as high as 83%, it is probable thatthe true prevalence of diverticulosis is between 20% and 50%, despite dealing with ayoung group of patients who have mostly died before the age of 60. Thediverticulosis does not seem to contribute directly to this excess mortality. The verywide range of quoted prevalences probably reflects the strong association ofdiverticulosis with end-stage renal failure (ESRF), which clearly often complicatesthe polycystic syndrome. A prevalence of diverticulosis of 58% has been reported inpatients with ESRF without a polycystic syndrome: this is therefore more probably anenvironmental/disease-related association.

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Session II

Clinical issues

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Definition(s) for diverticular disease

Edmund NeugebauerChirurgie, Krankenhaus Merheim, Köln, Germany

Intestinal diverticula were first described in 1899 by Ernst Graser from Erlangen.Today, diverticular disease is a common problem especially in Western Societies,where a low roughage diet and constipation as pathogenetic factors are moreprevalent. The continuously increasing age also contributes to this epidemiologicdevelopment. Diverticular disease can affect all parts of the intestine, but thisoverview is limited to the colon, because this is the most commonly and mostseverely affected site. In about two thirds of all cases, the sigmoid colon is involvedin the disease, but this distribution may be different for non-European populations.

Although there is no consensus on the best definition of diverticular disease, thefollowing terminology is commonly used to describe the different disease stages:Diverticulosis is an asymptomatic condition, which is characterised by herniation ofthe mucosa through the intestinal wall. This herniation occurs at points of weaknessin the colonic wall where blood vessels take their entry. The broad term diverticulardisease contains the word "disease" to indicate that this condition is associated withsymptoms. Symptoms may be mild and intermittent or acute and severe. In the lattercase, the disease is usually caused by inflammation of the colonic wall and/or thepericolic fat. In this sense, diverticulitis requires both the presence of diverticula andinflammation by definition. Inflammation is often caused by impacted faecal matter orfaecoliths. From a clinical point of view it is important to distinguish between first andrecurrent disease attacks. Finally, the term complicated disease or complicateddiverticulitis can be used to indicate the presence of haemorrhage, abscess,phlegmon, perforation, fistula, bowel obstruction or peritonitis).

The natural history of the condition is asymptomatic in most cases. Depending onthe age distribution, it is estimated that diverticulosis is present in about a third of thepopulation. Only a small proportion of this group, however, will develop symptoms oreven complicated disease. The course of the disease is chronic with intermittentattacks of diverticulitis. On the other hand, many cases who experience a singlesymptomatic attack will remain asymptomatic for the rest of their life. It is not fullyunderstood, by which mechanisms diverticular disease without inflammation leads tosymptoms, but it is believed that muscular hypertrophy plays an important role. Earlydisease stages are difficult to differentiate from Crohn's disease, ulcerative colitis,and irritable bowel syndrom. The overall yearly incidence of diverticulitis is about 10cases per 100.000 population.

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The most important complication of diverticulitis is perforation. Perforated diverticulardisease is best described by the use of the modified Hinchey classification. TheHinchey classification has never been validated with regard to their prognosticimportance, but it has proven useful when selecting diagnostic and therapeuticmodalities.

Severity grade Description

I Pericolic abscess

IIa Distant abscess amenable to percutaneous drainage

IIb Complex abscess with/without fistula

III Purulent peritonitis

IV Faecal peritonitis

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Prognosis of acute diverticulitis

PD Dr. med. Stephan HollerbachAllgemeines Krankenhaus Celle, Germany

The mere presence of diverticula in the colon without complaints is calledasymptomatic diverticulosis, which has an excellent prognosis if found acidentally(e.g. during screening colonoscopy). The utility of prophylactic fibre administrationremains unknown. However, an unknown percentage of patients with diverticulosisdevelops non-specific abdominal complaints without evidence of inflammation. Thissymptom complex is called symptomatic colonic diverticulosis. It shares manysimilarities with the irritable bowel syndrome (IBS), but the specific pathophysiologicfactors causing recurrent lower abdominal pain, bloating, and changes in bowlehabits remain to be identified. Only approximately 20% of diverticula carriers developinflammatory complications such as recurrent bouts of acute diverticulitis, which maycause significant morbidity and a low but distinct mortality rate, especially if notdiagnosed early or misinterpreted. The clinical spectrum ranges from mildinflammatory attacks with pain, leucocytosis, elevated serum ESR and CRP values,to a severe form of acute diverticulitis that may include life threatening complicationssuch as perforation, peritonitis, or development of fistula formations.. The "light" formof acute diverticulosis has an excellent prognosis and very low mortality rate iftreated promptly, which is usually performed conservatively consisting of fluid andelectrolyte correction, administration of antibiotics, and a short course ofnil-per-mouth followed by careful enteral feeding. Only 10-15% of patients requiresurgery. Colonoscopy should be performed after healing in all cases to rule outconcomitant cancer and complications such as obstruction and fistulas. Therisk-benefit analysis suggests that elective sigmoid resection is indicated after twoattacks of diverticulitis, which should be restricted to patients with general health andlow-risk procedures. In contrast, the severe form of acute diverticulitis has a seriousprognosis with a relatively high mortality, particularly in the presence of aggravatingfactors such as older age, and comorbidity. Surgery is required in most cases. Theindividual prognosis depends largely on these factors, while the overall mortality rateexceeds 30%. Conflicting clinical data suggest that patients who develop acutediverticulitis at age < 45 years may have a more virulent disease, with 66-88%requiring surgery during their initial attack and should be referred to electiveprophylactic surgery. However, as yet there is no evidence based rationalesupporting this concept. Immunocompromised patients have a great risk ofcomplications and usually require early interventions to ameliorate their individualprognosis.

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Session III

Diagnosis I

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Laboratory tests - what do they tell us?

Prof. Dr. Christoph GaschéMedizinische Universität Wien, Austria, christoph.gasche@meduniwien.ac.at

Diverticular disease is usually asymptomatic and does not require diagnosis ortreatment. Only in the case of complicating or symptomatic disease laboratory testsbecome relevant. The perfect marker would reflect disease extent, the severity ofinflammation, it would be independent of therapy unless inflammation decreases,and would be easy to assess and cheap. Routine blood tests for evaluation ofinflammation involve complete blood count, sedimentation rate, and C-reactiveprotein. This lecture will focus on the implications of any results of these tests onclinical management. Novel leukocyte-related markers such as calprotectin orlactoferrin can be quantified from feces and are currently used in IBD. They correlatewith 111indium-labeled leukocytes, however, their significance and superiority inevaluating diverticular inflammation has not been shown. Proinflammatory cytokineare regularly induced through intestinal inflammation and are thought to drive acutephase reaction. Complicating peritonitis may induce a shift from TH1- to TH2-T-cellresponse. Its diagnostic relevance has not been confirmed yet. In general, studies onthe biological significance of any test in diverticular disease are missing.

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Lower gastrointestinal bleeding - search for sources

Jürgen SchölmerichUniversitätsklinikum Regensburg, Germany

The incidence of bleeding is about 20/100.000/year. There is a 200 fold increasefrom the 3rd to the 9th decade. 24% of all bleedings have its origin in the lowerGI-tract, mortality is 2-4%. In many cases bleeding stops spontaneously,complications are much less frequent than in upper GI-bleeding. There is a shiftregarding the leading bleeding sources from younger age to older age. In the agegroup between 25 and 60 years diverticulosis is the most predominant source, inyounger people Meckel's diverticulum and IBD are more frequent, in patients over 60angiodysplasia and carcinoma increase in numbers.

The diagnosis is as always based on history and physical examination. Relevantquestions are related to the blood contents and quality in the feces, to pain, weightloss or fever. Laboratory parameters are of little value, clinical examinationdetermines severity of bleeding more than any other tests.

Technically endoscopy, scintigraphy and angiography can be used, more recentlywireless capsule endoscopy can be applied if the colon and the stomach have beeneliminated as a bleeding source.

When patients with hematochezia and upper GI-bleeding have been excluded,colonoscopy then has the dominant role. In a series of 2.449 patients significantfindings were obtained in 1.223. 10% of those were proximally located. 871 wererelated to diverticulosis. Scintigraphy is relatively sensitive to detect gastrointestinalbleeding but is not very exact regarding localization. Angiography needs higherbleeding intensity in order to detect the bleeding. A comparison of angiography andcolonoscopy demonstrated superior performance of colonoscopy.

All patients with acute lower gastrointestinal bleeding need to be stabilized prior toendoscopy. It is not yet clear if emergency colonoscopy with unprepared patients isbetter than prepared early colonoscopy with several hours delay. Detection rate ofcolonoscopy varies between 62 and 78%, the numbers are similar in emergencycolonoscopy.

Since meanwhile treatment of lower GI-bleeding is also mainly done byinterventional endoscopy and this can be applied to diverticular bleeding as well anattempt to perform endoscopy should be made. If endoscopy is impossible orendoscopic treatment not successful, angiography and local transvascular treatmentcan be applied. If this fails surgery may be required.

It is important to know that 80% of bleeding episodes stop spontaneously indiverticular bleeding. A relapse recurs in about 25% and is more frequent whenbleeding stigmata are visible. A third bleeding occurs in 50% after a second episode.Therefore, resection is recommended after a second episode by most centers andafter the first by some.

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Session IV

Diagnosis II

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Intestinal comorbidity

Heinz KrammerDepartment of Medicine II, University Hospital of Heidelberg at Mannheim, Germany

There can exist an intestinal comorbidity between diverticular disease andinflammatory bowel disease (Crohn’s disease, ulcerative colitis). The clinicalpresentations of constipation and/or diarrhea, hematochezia and mucus in the stool,abdominal pain, weight loss, fever, an abdominal mass, and fistulae can be identicalin acute Crohn’s disease and diverticulitis. Cases of diverticulitis respond to antibiotictreatment similar to acute Crohn’s disease. In addition, an apparently distinct form ofsegmental colitis associates with diverticula in the sigmoid has been described (overthe past two decades). Most of these patients are over 60 years old and suffer fromhematochezia, altered bowel function and abdominal pain. The pathogenesis of thisdistinct form of colitis and its relation to the diverticula remain unclear.

There can also exist an intestinal comorbidity between diverticular disease andirritable bowel syndrome (IBS). Both diseases are very frequent. One in six patientssuffering from diverticular disease has additionally IBS.

Diverticular disease can lead to chronic obstruction with IBS-like symptoms. Furtherit has been supposed that severe periods of inflammation may result in hyperalgesiaof the sigmoid. On the other hand, it is important to know that patients withdiverticular-associated symptoms usually do not suffer from frequently alternatingsymptoms, meteorism and passage of mucus. In contrast to IBS, diverticular diseasecommonly affects elderly individuals and the symptoms are not stress related.

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Symptoms in patients with diverticula - always diverticulardisease?

L.M.A. Akkermans and M. EkelundGastrointestinal Research Unit, Department of Gastroenterology and Surgery,University Medical Center, Utrecht, The Netherlands and Department of Surgery,Lund University Hospital, Sweden

The large majority of patients incidentally identified with diverticular disease willremain asymptomatic. Patients with symptomatic diverticular disease can be dividedin a subset with so-called chronically symptomatic uncomplicated diverticulosis andin a subset with well-defined complications of their disease. Patients with uncomplicated diverticulosis mostly present with non-specificsymptoms like pain in the lower abdomen, nausea, anorexia, fullness, bloating,irregular defecation, excessive flatulence, constipation, diarrhea, and passage ofmucus. Pain is generally exacerbated by eating and diminishes with defecation orflatus. The symptoms in these patients may not be attributed to diverticulosis beforefurther careful diagnosis and exclusion of colorectal carcinoma. Furthermore, it isclear that these non-specific symptoms overlap with those of Irritable BowelSyndrome (IBS). Symptom development is still unclear but chronic low-gradeinflammation; abnormal activation of intrinsic and extrinsic primary afferent neuronsleading to neural and muscular dysfunction may play a role in abdominal symptomsin diverticulosis as well as in IBS patients. This most likely plays a role in the ongoingsymptoms after bowel resection in patients operated electively after chronicuncomplicated diverticulitis.The differential diagnosis of patients with complicated diverticulitis is alsoproblematic.Possible diagnosis resembling chronic and/or acute diverticulosis are: colonicpathology, such as colorectal carcinoma, Inflammatory Bowel Disease (IBD),pseudomembranous or amebic colitis, appendicitis; urinary tract pathology, such asurinary tract infections and ureteric colic; vascular pathology, such as leaking ofabdominal aortic aneurysm; abdominal wall pathology, such as hematoma andhernia; and gynaecological disorders, such as ruptured ovarium cysts, ovariumtorsion, ectopic pregnancy and pelvic inflammatory disease. Here we want to focus on symptoms of chronic colonic diverticulosis/diverticulitis.For example, it has long been recognized that there exists an overlap betweenvarious forms of IBD and diverticular disease. The clinical presentation ofconstipation and/or diarrhea, hematochezia and mucus in the stool, abdominal pain,weight loss, fever, and abdominal mass, and fistula can be identical in bothdisorders. However, the microscopic findings of the two disorders differ. It isestimated that a substantial percentage of patients with colonic diverticulosis haverecurrent experience with inflammation and this means that post-inflammatorysymptoms of visceral hypersensitivity need to be considered.

In conclusion: In patients with divertivcula it is almost impossible to separatesymptom development of the diverticula itself and other anatomical and functionalabdominal disorders.

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Session V

Indications and controversies in imagingtechniques (round table)

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Colonoscopy in acute diverticulitis

Simon Bar-Meir, MDChaim Sheba Medical Center, Tel Hashomer, Israel

It is a common practice to postpone colonoscopy after an acute event of diverticulitisbecause of the potential risk of perforation. This policy is not evidence based. Weconducted a study aimed to evaluate the feasibility and safety of early colonoscopyin patients with acute diverticulitis.

Consecutive patients hospitalized for acute diverticulitis were included. In the firstphase of the study, patients with adjacent peri-diverticular air/fluid on CT wereexcluded. In the second phase of the study, only patients with free intra-peritoneal airwere excluded.

One-hundred and four patients with acute diverticulitis were included. Four patientswho had a colonoscopy within the previous year were excluded. Another 9 patientsrefused to participate in the study. The remaining 91 patients consisted the studypopulation. During the first phase of the study, 49 patients agreed to becolonoscoped. Ten were excluded because of peri-diverticular air/fluid. Theremaining 39 patients underwent uneventful colonoscopy. During the second phaseof the study, 42 patients agreed to have colonoscopy. Two were excluded becauseof free air in the peritoneum. The remaining 40 patients underwent colonoscopy andone with peri-diverticular air perforated her sigmoid colon. Complete colonoscopy tothe cecum or to the obstructing tumor was achieved in 65 patients (82%) . A secondcolonoscopy performed 6 weeks later in 13 of the remaining 14 patients wassuccessfully completed. Findings during the first colonoscopy were polyps in 7, polypwith infiltrating adenocarcinoma in one, obstructing adenocarcinoma in one and abone stuck in a diverticulum in another patient. The last two patients had a moreprotracted course and were clearly those who benfited most from the earlycolonoscopy.

Based on our study we concluded that early colonoscopy in acute diverticulitis isfeasible. It should be reserved either for all patients with no air adjacent to thediverticulum on CT or just for those with more refractory course.

An ongoing randomized study is presently being conducted on patients with acutediverticulitis and no peri-diverticular air. Such patients are being randomized intothose who undergo early colonoscopy and those who undergo colonoscopy 6 weekslater. All patients in both groups underwent a previous abdominal CT to excludecancer. Sixty patients were included in both groups and in none a significant lesionhas been identified (exept polyps). If these findings will hold with larger number ofpatients, abdominal CT should be enough to exclude colonic cancer. Colonoscopyshould be reserved only to patients with acute diverticulitis and a protractedunresolved course.

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Diverticular disease: Diagnostic value of ultrasound

S. SchanzEv. Krankenhaus Kalk, Köln, Germany

With the advent of small-parts und high-frequency probes, transabdominalsonographic assessment of the intestinum became an increasingly attractivediagnostic method. In spite of overlying gas, indications and experiencepredominantly in inflammatory and neoplastic bowel diseases have increased. Evenin diverticulosis an experienced sonographer can find the typical appearance ofnormal diverticulas of the left colon in most cases. They present as eccentrichyperechoic protuberances of the colonic wall with focal disruption of the normallayer and acoustic shadowing in a variable intensity caused by more or less gas.Together with segmental colonic wall thickening and pericolic inflammation andtypical hyperechoic outpouchings from the wall are consistent with acutediverticulitis. Other criteria are hypoechoic mesenteritis and abscess. Especiallywhen diverticulitis is diagnosed upon mural thickening and pericolic inflammation,other diseases with similar sonographic appearances can lead to false positiveresults, such as ulcerative colitis, Crohn’s disease, colonic cancer and otherinflammatory and neoplastic conditions. False negative findings result from theimpossibility to visualize the affected colonic segment, predominantly the lowersigmoid colon. Imaging methods currently available for patients with suspicion ofacute diverticulitis are CT and ultrasound. Several comparative studies have shownthat US is also an accurate method to detect acute inflamed bowel segments withsimilar results, supporting the use of US examination as the initial imaging techniqueand proposing to reserve CT for initial imaging of patients with clinical suspicion offree intraperitoneal perforation, generalized peritonitis and poor image quality.However, many surgeons prefer the use of CT as a standard method for initialdiagnostic because of limited access to an experienced gastrointestinalsonographer. Availability varies considerably among institutions and differentcountries. In the view of a physician dedicated to gastrointestinal sonography thisapproach is difficult to understand since US as an economical and less complexmethod without side-effects, repeatable at any time, provides rapid and valuablediagnostic information. To extend the method as a primary diagnostic tool andincrease its acceptance, more sonographic training and esteem is necessary.

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Diverticular disease: Diverticulitis: Contrast enema, CT, MRT

Prof. Dr. S. FeuerbachInstitut für Röntgendiagnostik, Klinikum der Universität Regensburg, Germany

Diverticular disease is a common entity. Different imaging modalities are applied todemonstrate the pattern of the disease and extraluminal complications. The role ofbarium enema, computed tomography and magnetic resonance imaging isdescribed.

Barium enema

Barium enema was considered the standard examination for diverticulosis anddiverticulitis in the past. It provides information on the number and location ofdiverticula in diverticulosis. The typical signs of diverticulitis in barium enemas arebowel wall edema, spasm, intramural fistulas and contrast extravasation, ifperforation occurred. Contrast enemas are limited, because extraluminal changesare not detected directly. The sensitivity of barium enemas to detect the disease isbetween 62 and 94% (1, 2). Only water soluble contrast material should be used, ifdiverticulitis is suggested.

CT

Computed tomography is the method of choice for the diagnosis of diverticulitis. TheCT of the abdomen and pelvis has to be performed using contrast medium i.v., orallyand rectally. The typical signs of diverticulitis on CT are pericolic infiltration of thesurrounded fat tissue, bowel wall thickening, abscesses, contrast mediumextravasation in cases of perforation and also small air bubbles, which cannot beidentified on abdominal plain films. Because CT demonstrates also the extraluminalcomplications of diverticulitis, which influence the management of the disease. CT issignificantly more accurate than contrast enemas. The sensitivity for CT is reportedto be 93-98% with a specificity of 75-100% (3, 4, 5, 6).

MRI

Many reports are available about MR colonography, but only one study deals withMRI based colonography for diagnosis and assessment of diverticulosis anddiverticulitis (7). In this prospective feasibility study 14 patients with clinicallysuspected diverticulosis or diverticulitis are examined. In all patients, spiral CT as thegold standard was available. Diverticulosis and inflammatory changes were detectedsimilar to spiral CT using MRI colonography. Also when MRI base colonographyoffers the same diagnostic quality as spiral CT, there are certainly severaldisadvantages. Compared to spiral CT, the MRI examination takes more than 20min. MRI is more prone to motion artefacts, and it is more difficult to monitor severelyill patients in the MRI suite. The spatial resolution is inferior to CT, and probably it isdifficult to assess free air within the abdomen using MRI. The method must still beevaluated in larger prospective clinical trials.

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References:

1 Shrier D, Skucas J, Weiss S. Diverticulitis: an evaluation by computedtomography and contrast enema: Am J Gastroenterol 1991; 86: 1466-1471.

2 The standards task force of the American Society of Colon and RectalSurgeons. Practice parameters for sigmoid diverticulitis: supportingdocumentation. Dis Colon Rectum 1995; 38: 126-132.

3 Doringer E. Computerized tomography of colonic diverticulitis. Crit Rev DiagnImaging 1992; 33: 421-435.

4 Hulnick DH, Megibow AJ, Balthazar EJ, Naidich DP, Bosniak MA. Computedtomography in the evaluation of diverticulitis. Radiology 1984; 152: 491-495.

5 Cho KC, Morehouse HT, Alterman DD, Thornbill BA. Sigmoid diverticulitis:diagnostic role of CT - comparison with barium enema studies. Radiology 1990;176: 111-115.

6 Ambrosetti P, Jenny A, Becker C, Terrier TF, Morel P. Acute left colonicdiverticulitis: compared performance of computed tomography andwater-soluble contrast enema: prospective evaluation of 420 patients. DisColon Rectum 2000; 43: 1363-67.

7 Schreyer AG, Fürst A, Agha A, Kikinis R, Scheibl K, Schölmerich J, FeuerbachS, Herfarth H, Seitz J. Magnetic resonance imaging based colonography fordiagnosis and assessment of diverticulosis and diverticulitis. Int J Colorectal Dis2004; 19: 474-80.

Correspondence:

Prof. Dr. S. FeuerbachInstitut für RöntgendiagnostikKlinikum der Universität Regensburg93042 RegensburgTel.: 09 41/9 44-74 01Fax: 09 41/9 44-74 02E-mail: stefan.feuerbach@klinik.uni-r.de

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Session VI

Determinants of treatment

41

Natural course of the disease

Dr. Marios Z. PanosEuroclinic, Athens, Greece

In Western populations diverticular disease of the colon (DD) is common. Itsprevalence increases with age. It is almost unknown in adolescents. Its prevalence is2-29% in the under 40s, 30-35% in those over 45 years and 42-66% in those over85. Left-sided disease predominates in the West (90-95%). In Asian populations DDprevalence varies from 4 to 25% with right-sided disease predominating (70%). InAfrica DD is rare.

Seventy to 80% of individuals with DD are asymptomatic. Only 20-30% havesymptoms such as pain (usually left-sided), cramps, bloating or constipation. About15-20% develop diverticulitis or its complications. Uncomplicated diverticulitisaccounts for 75% of these cases whilst the remaining 25% comprises diverticularabscesses, perforations, fistulae and strictures (almost invariably treated surgically).On a first admission with acute diverticulitis, 65-85% will respond to medicaltreatment, the remainder requiring surgery. Overall mortality for a first admission is1.3-5.7%. Those requiring surgery have a mortality of 12-17%. Perforateddiverticulitis carries a mortality rate of 28%. In patients with DD, obesity, young age,male sex and immunosuppression confer a high risk of acute diverticulitis andperforation.

Most patients with diverticulitis present with a short duration of symptoms. 8% give ahistory of previous attacks. In those who avoid surgery on the first admission, the riskof recurrence is about 2% per year. In the long-term, 1/3 patients will remainasymptomatic, 1/3 will have abdominal pain and 1/3 will have a further attack ofdiverticulitis or its complications. Patients who recover from a second attack ofdiverticulitis without surgery have a 90% chance of a further attack.

Diverticular haemorrhage (DH) occurs in 5-15% of those with DD. The risk ofbleeding increases with age and use of NSAIDs. In 1/3 cases the bleeding ismassive and 7% require surgery with a mortality rate of 2.2%. In cases wheresurgery is avoided during the first episode of DH, the risk of recurrence at 4 years is25%. After two episodes of DH the risk of rebleeding rises to 50%. There is evidenceto suggest that DH is more common in right sided DD.

The reported incidence of internal fistulas in patients with a history of diverticulitis is2%. Colovesical fistulae account for 65% and colovaginal for 25%. Treatment issurgical.

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Mechanisms of pain in diverticular disease

Professor R.C. SpillerWolfson Digestive Diseases Centre, University Hospital, Nottingham, NG7 2UH, UKTel.: 0115 9249924 ext 35077, E-mail: robin.spiller@nottingham.ac.uk

While two thirds of individuals with diverticulosis experience no symptoms, one thirdexperience recurrent pain and disturbed bowel habit1. Surprisingly radiologicalseverity of diverticular disease is not the best predictor of pain. However, previousepisodes of prolonged acute pain, suggestive of acute diverticulitis (> 7 daysincapacity with fever and often treated with antibiotics) is associated with a doublingof risk of recurrent pain. Such pain occurs in episodes which occur on 5 (2-13) daysper month [median (interquartile range)] and last a median of 3 (0.1-12 ) hours.Stools are variable and incontinence is surprisingly common occurring 3 (1-7) daysper week. The cause of this post diverticulitis pain is uncertain but several animalmodels have demonstrated prolonged post infective visceral hypersensitivityassociated with smooth muscle thickening reminiscent of the changes indiverticulitis2. Clinical studies have indicated an association of pain with increasedsigmoid pressure3. Others have shown evidence of altered sensitivity toacetylcholine4 and reduced responsiveness to nitric oxide donors4 in resectedsigmoid colon. Neural staining of sigmoid colon resected for complicated diverticulardisease shows morphological changes suggestive of nerve damge and regrowth. Inboth animal and human studies, inflammatory changes are followed by changes inneuropeptide expression with upregulation of tachykinins and galanin5. Thesechanges may underlie altered the visceral hypersensitivity shown in diverticulardisease.

Reference list:

1. Simpson J, Neal KR, Scholefield JH, Spiller RC. Patterns of pain in diverticulardisease and the influence of acute diverticulitis. Eur. J. Gastroenterol. Hepatol.2003; 15: 1005-1010.

2. Mayer EA,.Collins SM. Evolving pathophysiologic models of functionalgastrointestinal disorders. Gastroenterology 2002; 122: 2032-2048.

3. Cortesini C,.Pantalone D. Usefulness of colonic motility study in identifyingpatients at risk for complicated diverticular disease. Dis. Colon Rectum 1991;34: 339-342.

4. Golder M, Burleigh DE, Belai A, Ghali L, Ashby D, Lunniss PJ et al. Smoothmuscle cholinergic denervation hypersensitivity in diverticular disease. Lancet2003; 361: 1945-1951.

5. Simpson J, Sundler F, Jenkins D, Scholefield JH, Spiller RC. Increasedexpression of substance P, neuropeptide K and galanin in mucosal nerves inpatients with painful diverticular disease. Gastroenterology 2004; 126: A218.

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Determinants of treatment: Outcome measures

Jörg C. HoffmannMed. Klinik I mit Schwerpunkt Gastroenterologie/Infektiologie/Rheumatologie,Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, D-12200 Berlin,Germany (Direktor: Prof. Dr. med. M. Zeitz)

Diverticular disease is known as diverticulosis in association with "symptoms". Themost common underlying disease entities are bleeding diverticula and inflameddiverticula (diverticulitis). There is general agreement that an attempt can be made toendoscopically stop bleeding of diverticula when possible and to wait after bleedinghas stopped spontaneously since the rebleeding rate is low. However, patients thathave rebleeding need an operative resection of the bleeding bowel segment. Diverticulitis can be subdivided into complicated and uncomplicated diverticulitis.This distinction is of utmost clinical importance since it implies either a conservativeor operative treatment approach. There is no doubt, that perforation with fecalperitonitis is classified as "complicated" diverticulitis. However, the definition of"complicated" is less clear for the most common subgroup, i.e. patients withperidiverticulitis. This subgroup represents about 2/3 of all patients with diverticulitisthat enter the inpatient service. While many consider this subgroup as"uncomplicated" diverticulitis some argue that peridiverticulitis represents alreadycomplicated diverticulitis because of the perforation into paracolic tissue.Accordingly, some classification systems consider uncomplicated diverticulitis asinflammation confined to the wall while others require full perforation with abscessformation, fistulas or strictures. Still the most widely used classification is themodified Hinchey classification for perforated diverticular disease: I Pericolicabscess; IIa distant abscess; IIb complex abscess associated with/without fistula; IIIgeneralized purulent peritonitis; IV fecal peritonitis. Importantly, none of the multipleclassification systems is validated according to established criteria. Unfortunately,the vast literature on diverticulitis consists mostly of retrospective case series.Therefore, the available data must be interpreted with caution.The outcome of patients with diverticular disease depends on various parameters.The natural course and extraintestinal comorbidity were discussed in previousspeeches. Particularly the comorbidity, concomitant immunosuppression and youngage are risk factors for poor outcome. Outcome measures depend on the type oftreatment that was chosen for the individual patient. The reported operative mortalityrate ranges from 0.5 to 17% and conservative approach have rates up to 8%. Thelarge variation in the surgical studies can be explained by the disagreement on theindication for surgery. While some argue that all patients with peridiverticulitis shouldbe operated upon (giving a very low mortality rate for early elective surgery) othersonly operate upon severe complications particularly in an emergency situation(approx. 15-fold higher mortality rate compared to the elective situation). Clearly,operative mortality and morbidity can be reduced by percutaneous drainage ofencapsulated abscesses prior to elective surgery. After drainage, some seriessuggest that pericolic abscesses even do not need later surgery. If patients areoperated upon the complication rate varies again between 18 and 51% includingminor complications such as wound infections. Some complications such asanastomotic leakage usually need reoperation with rates up to 20%. Recurrence

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after an appropriate resection for complicated diverticulitis is as uncommon asrecurrence after medical treatment of mild diverticulitis (10-13%). However, mostseries report recurrence rates of up to 50% for those patients who had pericolicabscesses and were treated conservatively. Finally, many patients have furtherabdominal complaints after an initial episode of diverticulitis (12-54%).In summary, there exists some controversy as to the definition of "complicated"diverticulitis. In order to compare different studies, which are mostly retrospectivecase series, it would be of utmost importance to have a general classificationsystem. Therefore, at present, outcome from different studies cannot be comparedproperly looking at different treatment modalities, i.e. surgery, ultrasound/CT guideddrainage and/or antibiotics with bowel rest. Surgery, while most dangerous as anemergency procedure, causes significant morbidity even for the less severelyaffected patients. Prospective, randomized studies are therefore needed to comparethe results of operative and conservative treatment in patients with peridiverticulitis.

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Session VII

Surgery

47

Principles of surgical strategy

Prof. Dr. N. SenningerAllgemeine Chirurgie, Universitätsklinikum Münster, Germany

Surgical therapy in diverticular disease is directed towards the following goals:

1. to prevent development of complicated disease2. to treat complicated disease3. to treat recurrent disease4. to stop diverticular bleeding and5. occasionally to rule out a tumour.

The differential diagnosis of concomitant carcinoma and sealed or open perforationdue to carcinoma of the colon is not discussed further. Similarly, the situation ofbleeding colonic diverticula is only addressed briefly: Hemostasis is of utmostimportance. About 70 % of bleeding diverticula will stop spontaneously, the majorityof the rest will be dealt with endoscopically. However, if bleeding persists, theresection of the bleeding portion of the colon, preferably together with the so-calledhigh pressure zone and the sigmoid colon (if in continuity with the bleedingdiverticula) is usually carried out.

The treatment option of non-complicated diverticulitis is strictly conservative withbowel rest, evacuation and antibiotic treatment. There is widespread consensus thatpatients having had at least 2 bouts of uncomplicated diverticulitis, in additionyounger patients below 50 years of age should have an operation since it isassumed that further bouts are waiting und will be more severe than the previousones. This is, however, not evidence based, since most patients in fact do not sufferfrom further attacks and in many instances the first attack already is complicateddisease.

It is wise to use an internationally acknowledged staging system for complicateddisease. There are many staging and scoring systems available, a very useful one isthe classification according to Hinchey (I - IV):

I pericolic abscess or phlegmonII pelvic, intraabdominal or retroperitoneal abscessIII generalized purulent peritonitisIV generalized feculent peritonitis

Patients with stage I should be treated initially non-operatively utilizing intravenousbroad spectrum antibiotics. Elective resection and primary anastomosis severalweeks later is suggested for otherwise healthy persons, but there may be a role forobservation alone.

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Hinchey Stage II: These patients should be treated initially non-operatively involvingintravenous broad spectrum antibiotics, bowel rest and percutaneous abscessdrainage. Urgent operative intervention is only indicated if generalized peritonitis isdeveloping or there is a failure to respond to parenteral antibiotics and percutaneousdrainage.

Stage III: These patients require operative intervention after preliminary optimizationand resuscitation. At the discretion of the surgeon, during the operation according tothe overall situation of the patient a decision has to be made whether resection andprimary anastomosis, with or without proximal diversion, can be carried out safely orif Hartmann I procedure should be employed. Age of the patient andimmunocompromised status like immunosuppression are favoring the discontinuity,as applies to patients with ASA score > III. By all means the diseased segmentshould be removed during the first operation.

Stage IV: These patients as well require operation after preliminary optimization andresuscitation. Most of these patients are in a bad overall condition so Hartmann Iprocedure is the treatment of choice. Again, the diseased and perforated segmentsshould be removed during the first operation.

The diverticular disease may affect the sigmoid colon only or larger portions of thecolon including the whole colonic frame. Most of the disease will be associated withthe sigmoid colon. So the strategy for the operation, especially when preventingrecurrent disease is on one side the removal of the diseased colonic segment,usually the sigmoid colon. However, the colorectal junction area is alluded to as highpressure zone. This area should always be resected as well, since left behind evenin parts, theoretically stasis could occur. Thus, the general perception is that theanastomosis should always be to the rectum below the peritoneal fold.

Many of the principles of the surgical strategy have been derived from clinicalexperience, they are, however, not evidence based at a high evidence level. Sincefollowing the conventions described has yielded excellent results, the conduct ofrandomized studies will have to concentrate predominantly on the extent of resectionof non-diseased colon and the use of minimally invasive procedures.

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Extent of sigmoid resection

Abe FingerhutCentre Hospitalier Intercommunal, Poissy, France

The question of how long a segment should be resected in the case of surgery forsigmoid diverticulitis is not new: There is a time-proven, although notevidence-based, answer. Dependent on an "appropriate" length of resection are: a) alow (acceptable) rate of recurrence, b) a safe anastomosis, and c) satisfactorypatient comfort. In the elective setting, resection of the entire sigmoid colon has beenthe modern standard since the publication from the Mayo Clinic (Judd) in 1955where it was found that even when diverticula were present in the transverse or rightcolons, the sigmoid colon was the site of the severe complications in over 98% of thecases. According the other recommendations, the upper limit should remove allproximal foci of inflammation, leading to a safe anastomosis. This implies performingsometimes a left colectomy. The distal limit of excision, however, has given rise tomuch more discussion. Mann, Goligher, and Hughes, in their respective text bookchapters, as well as more modern authors including Wexner and Bergamachi, alladvocated including the sigmoid rectal juncture in the resection in order toanastomose the proximal colon to the upper rectum as the rates of recurrence andreoperations were higher when this was not the case, and the rectum itself wasrarely involved: This implies simple posterior mobilization of the rectum, removing nomore than the intraperitoneal segment of the upper rectum. The juncture isclassically determined by the disappearance of the taeniae coli and accessorily, achange in the aspect of the serosa.In the emergency setting, the rules should be the same, especially since one or twostage treatment should include resection of the infected segment of colon as part ofsource control, completed by at least that of the sigmoid colon for the remainingdiverticulae, as indicated above. The problems stem from the degree of inflammationand the severity of peritonitis which in some instances can lead to difficult decisionsas to the extent of resection necessary. Wexner's group (Thaler) recently compared the extent of resection betweenlaparoscopic and traditional sigmoid resection and confirmed that laparoscopicresection was as efficient. The overall implications are that: a) the splenic flexure should be taken downroutinely to ensure a safe tensionless anastomosis, b) the upper limit of theproposed resection should be land marked with a clip before starting the dissectionin order to be sure the entire proximal sigmoid is resected in the specimen, c) thesigmoid rectal juncture must be identified and resected in all cases, and d) theanastomosis has to be performed intracorporeally, whether through a traditionallaparotomy or by laparoscopy.

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Laparoscopic surgery in diverticulitis - still controversial?

V. Schumpelick, M. Stumpf, S. WillisChirurgische Universitätsklinik der RWTH Aachen, Germany

As part of the unrelenting trend toward minimizing the invasiveness of surgicalprocedures, laparoscopic and laparoscope-assisted procedures have gainedincreased prominence in the treatment of uncomplicated diverticulitis of the sigmoidcolon. Current data leaves no doubt that laparoscopic sigmoid resection has its placein the treatment of diverticulitis. Although most experience has been gained inpatients undergoing elective resection, more and more patients with acute andcomplicated diverticulitis are being treated with minimally invasive surgery. Whilelaparoscopic intervention is theoretically possible even in emergency situations,there are no generally documented advantages to this approach. Despite the factthat laparoscopic intervention is routinely performed in many clinics, including ourown, it has not been established as the standard of care in prospective, randomizedstudies.

Currently available data, mostly derived from retrospective studies, point to anadvantage of laparoscopic surgery in terms of more rapid advance in diet, reducedanalgesic use, shortened hospital stay and a lower rate of incisional hernia withequivalent success rates (Scheidbach 2004, Schwandner 2004, Willis 2004).However, because of the unavoidable selection bias associated withnon-randomized studies, the excellent surgical results must be treated with caution.In addition, since most findings are reported from highly specialized departmentswith broad laparoscopic experience, they may not be directly applicable to thegeneral surgical community.

The advantages of shorter hospital stays are completely outweighed by the results of"fast track" surgery, to say nothing of longer periods in the operating room and theenhanced technical requirements of the laparoscopic procedure. Whetherlaparoscopic resection is advantageous in terms of cost is also unclear. In fact,currently available data suggest that laparoscopy may actually be more expensivethan conventional open surgery, which, based on DRG principles and inconsideration of the fast-track concept, would give the advantage to conventionalsurgery. Long-term observations have also not demonstrated any advantage for thelaparoscopic procedure in terms of recurrence rates and quality of life.

Elective laparoscopic sigmoid resection is relatively simple and is associated with ahigh success rate in patients with chronic Hinchey stage I disease. For higherHinchey stages, however, laparoscopic resection is more difficult and cannot begenerally recommended. In many cases, even physicians with broad laparoscopyexperience are confronted with a situation that requires conversion to conventionalopen surgery. Current data suggests that patients converted to open surgery have ahigher risk of complications and longer hospitalizations than do patients primarilyundergoing open surgery. Hence, there is usually no clear indication for laparoscopicsurgery in patients with acute complicated diverticulitis.

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Conclusion: Diverticulitis is a disease entity in which conservative treatment,conventional open surgery and laparoscopic surgical methods all have their place. Inspecialized centers, laparoscopic sigmoid resection has increasingly and justifiablybecome "state of the art" in uncomplicated sigmoid diverticulitis. Nevertheless it isimportant to remember that laparoscopic surgery should not be considered in casesin which patient-related, infrastructural and personnel requirements are not met. Inacute, complicated diverticulitis laparoscopic surgery cannot be generallyrecommended. Long-term observations also have failed to show any advantages forlaparoscopic procedures in comparison with conventional open surgery.

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Session VIII

Medical treatment

55

Bulking agents as a therapy for diverticular disease: Fact orfiction

Dr. James LindsaySt. Bartholomew's Hospital and The Royal London Hospital, London, UK

Diverticular disease is a common condition with a prevalence that increases withage, affecting up to 66% of patients aged 80 years or older. Although 75% patientswill remain asymptomatic; the condition leads to a significant morbidity and mortalityoften requiring complex surgery.There is good epidemiological evidence that diverticular disease is less common inthose taking a high fibre diet (rural Africans and vegetarians). Prospective data from47,000 American males has shown a relative risk (CI) for developing diverticulardisease of 0.58 (0.41-0.83; p < 0.01) in subjects in the highest quartile for fibreconsumption compared to the lowest quartile. This has led to the widespreadpractice (75% of surveyed practicing gastroenterologists) of prescribing fibresupplementation to patients as both a preventative and therapeutic strategy.However, only 5 controlled trials of less than 250 patients have been reported in theliterature. Whereas it is clearly demonstrated that a high fibre diet increases faecalweight, decreases colonic transit time and reduces constipation, evidence ofimprovement in other symptoms associated with diverticular disease is morecontroversial.

Diverticular colitis is a chronic symptomatic inflammatory condition of the bowel oftendifficult to distinguish from Crohn's, infective or ischaemic colitis. Open label datasuggest that diverticular colitis responds to fibre supplements, antibiotics andaminosalycilates. Recent work has investigated the effects of fibre supplementscontaining prebiotic non digestible carbohydrates on the interaction between theintestinal microbiota and the mucosal immune system. It remains to be seen whetherthis novel therapeutic strategy will be effective in symptomatic diverticular diseaseand diverticular colitis.

In summary, the evidence base for the use of fibre in diverticular disease isextremely limited despite the fact that it is routine clinical practice. Furtherrandomised double blind controlled trials are required to determine whether highfibre diets are truly effective as a therapy for diverticular disease, or whether theysimply reduce constipation.

Address for correspondence:

Dr J LindsayThe Endoscopy UnitThe Royal London HospitalWhitechapel, London E1 1BB / UKTel.: +44 (0) 2073777443Fax: +44 (0) 2073777441E-mail: james.lindsay@bartsandthelondon.nhs.uk

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Antibiotics in the treatment of diverticular disease of the colon

Giovanni LatellaDepartment of Internal Medicine, Gastroenterology Unit, University of L'Aquila,L'Aquila, Italy

Diverticular disease of the colon is very common in Western developed societies. Itis associated with aging and reduced intake of dietary fibre. Diverticular disease hasa broad range of clinical manifestations. The majority of patients with diverticula ofthe colon remain asymptomatic all their lives, a condition commonly referred to asdiverticulosis or asymptomatic diverticular disease. About 20% of individuals withcolonic diverticula develop symptoms and signs of illness, the symptomaticdiverticular disease including either the form without inflammation of the colon or thatwith inflammation termed diverticulitis. Diverticular disease of the colon may besymptomatic uncomplicated, recurrent symptomatic and complicated disease. Lessthan 5% of patients will develop major complications such as perforation withabscess, diffuse peritonitis or fistula, obstruction, and massive bleeding. No reliableindicators are available, as yet, to distinguish patients who will become symptomaticfrom those who will not. Furthermore, no data are available indicating signs andsymptoms that might predict the severity of the disease.There is a general consensus that conservative treatment is indicated in patientswith a first attack of uncomplicated diverticulitis, since about 70% of patients treatedfor a first episode will recover and have no further problems. Those with recurrentattacks have a 60% risk of developing complications. Conservative treatment ofdiverticular disease is aimed at relief of symptoms and at prevention of majorcomplications. Antibiotics are commonly used in the treatment of diverticulardisease, although clinical trials, comparing antibiotics with placebo or evencomparing various antibiotics, are lacking. Their use is based on general condition ofthe patient, clinical experience and the hypothesis of bacterial involvement(Gram-negative and anaerobic bacteria). The choice of antibiotic to be used variesaccording to the various clinical scenarios of the diverticular disease of the colon. There are no data available in support of any therapeutic recommendations orroutine follow-up in the large population of patients with asymptomatic diverticulardisease, although it is reasonable to recommend a high-fibre diet, also consideringthe potential health benefits of fibres, in general. No antibiotics should be prescribedin this condition.The efficacy of fibre supplementation in the treatment of symptomatic diverticulardisease without inflammation of the colon still remains controversial. There isevidence that long-term cyclic administration of poorly absorbed oral antibiotics (e.g.neomycin, paromomycin, rifaximin) combined with fibre supplementation significantlyimproves symptoms of uncomplicated diverticular disease. An unresolved issue isthe effectiveness of these antibiotics in the prevention of diverticulitis and relatedmajor complications. Antibiotics are commonly used in the treatment of diverticulitis. Variations in themanagement of uncomplicated diverticulitis have been reported, especially in termsof antibiotic choice, discharge instructions and follow-up out of the patients. Patientswith mild diverticulitis can be treated as outpatients with a liquid diet andbroad-spectrum oral antibiotics (nitroimidazoles, fluoroquinolones). Patients with

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severe diverticulitis require hospitalization, bowel rest, intravenous fluid treatmentand intravenous antibiotics active against the colonic anaerobic and Gram-negativeflora, especially E. coli and Bacteroides. Recommended antibiotic regimens, basedmore on clinical consensus than randomized trials, include either the combinationregimens (antibiotic polytherapy) or the single agent coverage (antibioticmonotherapy). The former include antianaerobic coverage with nitroimidazoles (e.g.metronidazole) or lincosamides (e.g.clindamycin) and Gram-negative coverage withan aminoglycoside (e.g. gentamicin, tobramicin), monobactam (e.g. aztreonam) orthird-generation cephalosporins (e.g. ceftazidime, cefotaxime). The latter is a singleagent coverage with second-generation cephalosporin (e.g. cefoxitin, cefotetan) or$-lactamase inhibitor combinations (e.g. sulbactam-ampicillin, tircacillin-clavulanicacid, tazobactam-piperacillin) or carbapenems (e.g. imipenem-cilastatin,meropenem). Failure to improve with conservative intensive medical therapywarrants a search for complications of the disease, consideration of alternativediagnosis and surgical consultation. Surgery is recommended in patients withrecurrent attacks of diverticulitis, patients with complicated diseases, or in young orimmunocompromised patients. As diverticulitis recurs in a low percentage ofpatients, surgery is not generally indicated after a single uncomplicated episode ofdiverticulits. Intravenous antibiotics are always recommended in the peri-operativeperiod of any surgical procedure performed for diverdicular disease of the colon.

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Probiotics

P. GionchettiDept. of Internal Medicine and Gastroenterology, University of Bologna, Italy

Diverticular disease of the colon is very common in Western countries and itsfrequency is strikingly correlated with advancing age.Treatment of diverticular disease is aimed at the relief of symptoms (such asabdominal pain, discomfort, bloating) and to prevent major complications.Some observations suggest a possible role of gut microflora in determiningsymptoms related to diverticular disease.Broad spectrum antibiotics are commonly used in the treatment of diverticulitis;recently the non-absorbable antibiotic rifaximin was effective in determining asymptomatic relief in diverticular disease.Probiotics are defined as living microorganisms, which upon ingestion in adequateamount exert health effects beyond inherent basic nutrition (14). Bacteria associatedwith probiotic activity are most commonly lactobacilli, bifidobacteria and streptococci,but others non-pathogenic bacteria such as some strains of Escherichia coli andnon-bacterial organisms, such as the yeast Saccharomyces boulardii, have beenused. Only 1 controlled trial has been carried out with probiotics in diverticular disease. Thenon-pathogenic Escherichia coli strain Nissle (Mutaflor capsules, 2.5 x 10 (10) viablebacteria/capsule) significantly improved the symptoms in uncomplicated diverticulardisease.Large double-blind, placebo-controlled trials are now recommended.

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Aminosalicylates

V. GrossKlinikum St. Marien Amberg, Germany

Aminosalicylates show a broad spectrum of antiinflammatory activity. They inhibitmany key factors of the inflammatory cascade, e.g. cyclooxygenase, thromboxansynthetase, platelet activating factor synthetase, production of IL-1 and of freeradicals. Aminosalicylates have an antioxidant activity. In addition, they interfere withthe interaction of intestinal bacteria and epithelial cells. This is the rationale for theuse of aminosalicylates for the prevention and treatment of symptomatic diverticulardisease. Symptomatic diverticular disease comprises a wide spectrum of pathologicconditions ranging from slight mucosal irritation to perforated diverticulitis. In acutediverticulitis treatment with antibiotics is indispensable, but aminosalicylates couldproduce favourable effects in the long-term treatment and prevention of relapses.This question has been addressed by several studies.

Trespi et al. (1) evaluated the efficacy and tolerability of mesalazine in theprophylaxis of diverticular disease. During a 4 year follow-up mesalazine reduced thefrequency of symptomatic recurrences and microhaemorrhagic phenomena and theduration of abdominal pain significantly. Tursi et al. (2) compared the efficacy of acombined treatment with rifaximin and mesalazine vs. rifaximin alone in patients withrecurrent diverticulitis. During a follow-up of 12 months a symptomatic recurrence ofdiverticulitis occurred in 3/109 patients treated with rifaximin + mesalazine, and in13/109 patients treated only with rifaximin. In a prospective study Brandimarte et al.(3) tested the effectiveness of a treatment with rifaximin/mesalazine followed bymesalazine alone in 90 consecutive patients with uncomplicated diverticulitis. 86patients were completely asymptomatic after 8 weeks of treatment with mesalazinealone. 2 patients showed recurrence of symptoms, and 2 patients developeddiarrhea. The aim of another study (4) was to evaluate the efficacy of mesalazine inthe relief of symptoms in patients with symptomatic and uncomplicated diverticulardisease. Patients treated with mesalazine showed al lower global symptom score ascompared to patients treated with rifaximin after 12 months of follow-up.

In summary, the available data suggest that mesalazine has favorable effects givenin addition to antibiotics in uncomplicated diverticulitis and may prevent recurrence ofsymptomatic diverticular disease. These findings should be confirmed inwell-designed placebo-controlled randomized clinical trials.

References:

1) Trespi E, Colla C, Panizza P, Polino MG, Venturini A, Bottani G, De Vecci P,Matti C:Therapeutic and prophylactic role of mesalazine (5-ASA) in symptomaticdiverticular disease of the colon.Minerva Gastroenterol Dietol 1999; 45: 245-252.

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2) Tursi A, Brandimarte G, Daffina R:Long-term treatment with mesalazine and rifaximin versus rifaximin alone forpatients with recurrent attacks of acute diverticulitis of colon.Digest Liver Dis 2002; 34: 510-515.

3) Brandimarte G, Tursi A, Elisei W, Annunziata V, Villa S:Rifaximin/mesalazine followed by mesalazine alone is highly effective inobtaining remission of uncomplicated diverticulitis of colon.Digest Liver Dis 2004; 36: S 202 (P0054).

4) Giovanni A, Leandro G, Fanigliulo L, Cavestro G, Comparato G, Cavallaro L,Muzzetto P, Franze A, Di Mario F:Efficacy of mesalazine in the treatment of symptomatic diverticular disease.Gastroenterology 2004; 126 (4, Suppl. 2) A-253.

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Medical treatment - analgesics/spasmolytics

Professor Hubert Mönnikes, MD MScCharité - University Hospitals and School of Medicine, Department of Medicine,Division Hepatology and Gastroenterology, Campus Virchow-Clinics, Berlin,Germany

Symptomatic Medical Treatment in Uncomplicated Diverticulosis

The majority of patients with diverticulosis either have no symptoms, or symptoms ofsuch minor nature that they never seek medical attention. However, recurrentabdominal pain and alteration of bowel habits occur in some patients with diverticulabut without evidence of inflammation and its complications (i.e. perforation, abscess)or mechanical obstruction and indicate the need for symptomatic medical treatment.Convincing evidence suggests that alterations in GI motility and visceral sensitivityare closely associated with symptoms in uncomplicated diverticular disease. Theseobservations provide a good rationale for using spasmolytics or antinociceptiveacting compounds in this condition. Therefore, it is very surprising that norandomized clinical trials assessing the efficacy of such compounds in symptomaticdiverticular disease have been performed.

Patients with symptomatic diverticulosis have increased duration of rhythmic,low-frequency, contractile activity, and these regular rhythms are associatedsignificantly with reporting of abdominal pain (Bassotti G et al. Clin GastroenterolHepatol 2005; 3: 248-253). These patients have also been shown to have highermotility indices than either asymptomatic patients or healthy controls (Cortesini C etal. Dis Colon Rectum 1991; 34: 339-342). Compared with controls, a preponderanceof excitatory cholinergic nerves and a diminution of action of non-adrenergic,non-cholinergic inhibitory nerves by nitric oxide have been found in diverticularcolons (Tomita R et al. Hepatogastroenterology 2000; 47: 692-696), which suggeststhat an imbalance in usual excitatory and inhibitory influences could favour enhancedtonicity. Taken together, hypermotility of the diverticular colon suggests that spasmolytics,e.g. anticholinergic or antispasmodic drugs, might improve symptoms by diminishingmuscular contraction. Nonetheless, no adequately controlled therapeutic trials haveshown a benefit.

There is evidence that diverticulitis may be the trigger that changes a largelyasymptomatic condition into a symptomatic one in diverticular disease: Episodes ofprolonged, presumed inflammatory pain due to diverticulitis are frequently followedby recurrent, short-lived pain similar to that seen in IBS (Simpson J et al. Eur JGastroenterol Hepatol 2003; 15: 1005-1010). Therefore, assuming postinflammatoryneural and muscular changes are important, one can propose that visceralanalgesics, e.g. antinociceptives like amitriptylline, or spasmolytics, e.g.smooth-muscle relaxants effective in IBS, provide a more specific pharmacologicalapproach than use of dietary manipulation. However, no adequate randomizedclinical trials assessing the efficacy of such compounds have been performed, andantispasmotics, e.g. tiropramide hydrochloride, have been shown only in small trials

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to be effective in the treatment of uncomplicated diverticular disease (De Masi E.Minerva Med 1989; 80: 587-590).

In contrast, no rationale exists for use of narcotic analgesics in uncomplicateddiverticular disease; and in diverticulitis morphine should be avoided as it has beenshown to increase intracolonic pressure.

Prophylactic Medical Treatment in Uncomplicated Diverticulosis

A protective association between calcium channel blockers (CCB) and perforateddiverticular disease has been shown that is confined to modified-releasepreparations (OR = 0.3; Morris CR et al. Gut 2003; 52: 1734-1737). In contrast, noprotective effect against perforation was found for antimuscarinic drugs.Excessive colonic segmentation increases intracolonic pressure which causes aweakening of the thin diverticular wall. Also, impairment of the mucosal barrier of thediverticulum through alterations in mucus secretion, epithelial cell function, ormicrobial colonisation may lead to further weakening. Therefore, drugs that reduceintracolonic pressure or protect the mucosa may help prevent perforation. CCB relaxGI smooth muscle and reduce the frequency of pressure waves in the colon; theyhave been shown to suppress the colonic pressure waves normally associated withparasympathetic stimulation or eating, particularly in patients with colonichypercontractility. Antimuscarinic drugs have similar effects in blocking extrinsicstimuli but do not affect slow wave activity. The lack of protective effect forantimuscarinics may indicate that suppression of slow wave amplitude and durationis important in protecting against perforation. Alternatively, CCB may be actingthrough increasing GI mucosal blood flow, helping to promote cytoprotective activityand repair in the diverticular mucosa. Patients who may benefit from CCB prophylaxis are those who have undergoneprevious surgical resection because of episodes of inflammation, since up to 13% ofthese patients will develop recurrence of their disease after surgery. Another groupof patients who may benefit from prophylaxis are older individuals with knowndiverticular disease and hypertension.

Side Effects of Analgesics in Diverticular Disease

HaemorrhageNSAIDs and AcetaminophenRegular and consistent use of NSAIDs and acetaminophen has been shown to bepositively associated with the relative risk (RR) of symptomatic diverticular disease(users vs. nonusers, RR for NSAIDS = 2.24; RR for acetaminophen = 1.81). Most ofit was attributable to cases associated with bleeding, particularly for acetaminophen(RR for NSAIDs = 4.64; RR for acetaminophen = 13.63). The effects of the NSAIDscould be due to inhibition of PG synthesis which exerts a GI cytoprotective effect.Acetaminophen is also a weak inhibitor of cyclooxygenase; thus it can induce PGdeficiency with loss of mucosal protection and bleeding due to defective plateletfunction (Aldori et al. Arch Fam Med 1998; 7: 255-260).

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PerforationNSAIDs There is evidence that NSAIDs are a possible causative factor in perforateddiverticular disease (OR = 4.0), probably by impairing the integrity of the mucosa(Morris CR et al. Br J Surg 2003; 90:1267-1272). Although NSAIDs use is thestrongest known predictor of colonic perforation, this risk factor can only account forless than a fifth of the cases of perforations (Eur J Gastroenterol Hepatol 2000;12:661-665).In addition, it has been shown that patients with diverticular disease who developedsevere perforations were approximately three times as likely to be using NSAIDs atthe time of perforation compared with those with uncomplicated diverticulosis anddiverticulitis (Ann R Coll Surg Engl 2002; 84: 93-96).

Opiate analgesics Opiate analgesics are another class of drugs that has recently been recognized as apotential risk factor for perforated colonic diverticular disease: A recent case-controlstudy showed a positive association of opiod analgesics and diverticula perforation(OR = 1.8) becoming even stronger when opiate analgesics were used on a dailybasis (OR = 4.1; Morris CR et al. Br J Surg 2003; 90:1267-1272). This could be dueto the fact that opiate analgesics slow colonic transit time and elevate pressurewithin the colon (Gut 1964; 5: 207-213; Life Sci 1986; 38: 671-676).

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Session IX

Treatment - miscellaneous

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Combined surgery for diverticular disease and comorbidity

H.P. BruchUniversitätsklinikum Schleswig-Holstein, Campus Lübeck, Germany

Diverticular disease of the sigmoid colon affects more than 50% of people older than60 years, and the incidence is known to increase with age. Most patients remainasymptomatic, but 10 to 20% develop complications requiring surgery.

Surgery for diverticular disease is indicated in acute complicated and chronicallyrecurrent diverticular disease. In patients with acute complicated diverticular diseaseand with respect to clinical appearance surgery should be performed early electivewithin 5 to 7 days after the acute episode following initial conservative treatment(bowel confinement; total parenteral nutrition; parenteral antibiotics). In patients withchronically recurrent diverticulitis, elective colectomy is recommended after thesecond inflammation episode, with special reference to patients under 50 years ofage for whom resectional surgery is recommended after the first episode ofinflammation. Concerning the appearance, it has been shown that laparoscopicresection is safe and effective.

As diverticular disease is a typically illness of the Western countries, the surgeon isnot seldom confronted with other intraabdominal comorbidities, e.g. symptomaticcholecystolithiasis, defined colonic polyps or adhesions prior to previous surgery. Inthese cases, sigmoid resection can be combined with additional procedures, e.g.cholecystectomy or adhesiolysis. As diverticular disease is frequently associatedwith pelvic floor disorders, such as outlet obstruction, descending perineumsyndrome (DPS), or rectum prolaps, sigmoid resection can be performed withsimultaneous rectopexy or pelvic floor reconstruction.

Finally, the risk of the defined polyps as well as the incidence of colonic carcinoma(particularly related to sigmoid stenosis) seems to be underestimated. Therefore,oncological and anterior resection should be recommended in sigmoid stenosissuspicious of malignancy.

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Diverticular disease: Persistent symptoms after surgery

Matthias K. Peter, Daniel Candinas, Bernhard EggerDepartment of Visceral and Transplantation Surgery, University of Bern, Switzerland

Introduction: According to the sparse literature persistent symptoms followingsurgery of diverticular disease are observed in up to 27%. However, recurrentdiverticulitis occurs only in 1-10%. The aim of our study was to evaluate our ownpatient collective concerning persistent symptoms after surgery for this disease.

Methods: A review of our prospective colonic surgery database between Jan. 1999and Dec. 2004 identified 162 patients (80 females, 82 males) with a mean age of 63(28-96) years who had undergone surgery for diverticular disease. All patient wereoperated by a standardized intervention (resected colon > 20 cm; distal margin wellin the proximal rectum). In April 2005 124 (77%) of them could be contacted forfollow-up with a mean follow-up time of 33 (4-72) months. 23 (14%) died in the meantime (not directly related to the operation) and 15 (9%) have been lost for follow-up.Of these 124 patients 55% underwent elective and 45% emergency operation.Indication for elective operation was recurrent non-complicated diverticulitis in 64(94%) and complicated diverticulitis (free perforation, extended abscess, ileus due tostenosis, fistula) in 4 (6%) patients. Complicated diverticulitis was the indication foran emergency operation in 84%. 54% of them received a bowel discontinuityoperation (22 Hartmann-operation and 7 protective ileostomies) with reconstitution ofbowel continuity after approximately 3 months. 30% of all patients (53% of electivelyoperated) underwent a laparoscopically assisted resection.

Results: Persistent symptoms after a mean of 33 months follow-up were present in31 patients (25%). Symptoms were constipation in 11, abdominal distensions in 7,crampy pain in 7 and diarrhoea in 7 patients. Recurrent diverticulitis was observed in1 patient. Quality of life concerning the surgical intervention at the time of the lastfollow-up was very good in 51%, good in 42%, moderate in 6% und poor in 1% of thepatients. No significant differences in presence of persistent symptoms were foundcomparing elective and emergency cases as well as comparing open andlaparoscopically operated patients out of the electively treated group.

Conclusions: Persistent mild symptoms are present in 25% of our patientscollective after surgery for diverticular disease. Recurrent diverticulitis is seldomwhen standardized indications and procedures are used/performed to treat thisdisease. Whether the surgical technique (open, laparoscopic) nor the type ofintervention (elective, emergency) has any significant influence on the presence ofpersisting symptoms.

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Primary and secondary prevention of diverticular disease

Walid H. Aldoori, MD, MPA, ScD Wyeth Consumer Healthcare Inc., Scientific Affairs, 5975 Whittle Road, Mississauga,Ontario, L4Z 3M6, Canada, E-mail: aldoorwa@wyeth.com

Diverticular disease (DD) is one of the most common disorders of the colon inWestern societies. This is in sharp contrast to its rarity in many developing countries,however, there is recent evidence that the incidence of DD is increasing, particularlyin urban settings. The condition is more common among older people and thenumber of individuals diagnosed with DD is expected to increase exponentially asthe elderly population grows. It is suggested that lifestyle factors can explain theincrease in the incidence of DD, and identifying these factors is important in theprevention of DD and/or the complications of DD. The main hypothesis suggested byPainter and Burkitt for the increase in incidence of DD was the decline in dietary fiberintake, particularly cereal fiber intake. Three decades have passed since thishypothesis was widely publicized. Since then, several studies have investigated theassociation between fiber, fiber sources, other dietary components, and lifestylefactors and DD. To minimize the potential of bias, dietary and non-dietary factorswere investigated prospectively among 51,529 health professional men participatingin an ongoing cohort study. In summary, our prospective data supported the hypothesis that high intake ofdietary fiber mainly from fruits and vegetables reduces the risk of DD. Evidenceindicates that the insoluble component of fiber is strongly associated with lower riskof DD and this association was particularly strong for cellulose. Higher consumptionof fat and red meat increased the risk of DD. Risks were particularly elevated amongmen with the combination of high intake of total fat or red meat and low consumptionof dietary fiber. Caffeine and alcohol intake do not seem to be associated withincreased risk of DD. Unlike other colonic disorders, smoking does not appreciablyincrease the risk of DD after controlling for potential confounding factors. Overallphysical activity was inversely associated with the risk of DD and most of the inverseassociation was attributable to vigorous activity. There was a weak positiveassociation between increasing body mass index (BMI) and the risk of DD. There isevidence that regular and consistent use of non-steroidal anti-inflammatory drugs(NSAIDs) and acetaminophen is associated with complicated DD. Most of thispositive association was attributable to cases associated with bleeding, particularlyfor acetaminophen. In conclusion, a diet high in fiber and low in total fat and redmeat and a lifestyle with more physical activity might help prevent DD.

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List of Speakers, Moderators and Scientific Organizers

Prof. Dr. L.M.A. AkkermansAcademisch Ziekenhuis Utrechtde UithofDept. of Experimental Surgery G. 04.228Box 85500NL-3508 GA UtrechtThe Netherlands

Dr. W.H. AldooriWyeth Consumer Healthcare Inc.Medical Director5975 Whittle RoadMississauga, ON L4Z 3M6Canada

Prof. Dr. M. AnthuberAllgemeinchirurgieKlinikum AugsburgStenglinstr. 2D-86156 AugsburgGermany

Prof. Dr. S. Bar-MeirChaim Sheba Medical CenterDepartment of Gastroenterology2 Sheba RoadIL-52 621 Tel HashomerIsrael

Prof. Dr. H.P. BruchUniversitätsklinikum Schleswig-Holstein, Campus LübeckChirurgieRatzeburger Allee 160D-23562 LübeckGermany

Prof. Dr. M. CainzosUniversidade deSantiago de CompostelaFacultade de Medicina e OdontologiaRua de San Francisco s/nE-15782 Santiago de CompostelaSpain

Prof. Dr. R. CohenSt. Mark's HospitalDepartment of SurgeryLevel 5xWatford RoadHarrow HA1 3UJGreat Britain

PD Dr. B. EggerInselspitalKlinik für Viszerale undTransplantationschirurgieCH-3010 BernSwitzerland

Prof. Dr. S. FeuerbachRöntgendiagnostikKlinikum der Universität RegensburgD-93042 RegensburgGermany

Prof. Dr. A. FingerhutCentre Hospitalier IntercommunalF-78303 PoissyFrance

Prof. Dr. W.E. FleigInnere Medizin IMartin-Luther-UniversitätHalle-WittenbergErnst-Grube-Str. 40D-06120 HalleGermany

Dr. A. ForbesSt. Mark's HospitalDigestive DiseasesResearch CentreWatford RoadHarrow HA1 3UJGreat Britain

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Prof. Dr. C. GaschéUniversitätskliniken WienKlinik für Innere Medizin IVWähringer Gürtel 18-20A-1090 WienAustria

Prof. Dr. P. GionchettiUniversità di BolognaPoliclinico S. OrsolaIstituto di Clinica e GastroenterologiaVia Massarenti 9I-40138 BolognaItaly

Prof. Dr. B. GökeInnere Medizin IIKlinikum der UniversitätMünchen-GroßhadernMarchioninistr. 15D-81377 MünchenGermany

Prof. Dr. V. GrossKlinikum St. Marien AmbergInnere Medizin IIMariahilfbergweg 7D-92224 AmbergGermany

Prof. Dr. N.Y. HaboubiTrafford General HospitalSurgical PathologyMoorside Road, DavyhulmeManchester M41 5SLGreat Britain

PD Dr. J.C. HoffmannMedizinische Klinik ICharité UniversitätsmedizinCampus Benjamin Franklin (CBF)Hindenburgdamm 30D-12203 BerlinGermany

PD Dr. S. HollerbachAllgemeines Krankenhaus CelleGastroenterologieSiemensplatz 4D-29223 CelleGermany

Prof. Dr. C. HüscherOspedale San GiovanniDepartment of SurgeryVia dell'Amba Aradam, 9I-00184 RomItaly

Prof. Dr. K.-W. JauchChirurgieKlinikum der UniversitätMünchen-GroßhadernMarchioninistr. 15D-81377 MünchenGermany

Prof. Dr. J. JeekelErasmus Medical CenterDepartment of SurgeryDr. Molewaterplein 40NL-3015 GD RotterdamThe Netherlands

Prof. Dr. R. JonesUMDS of Guy's &St. Thomas HospitalsDepartment of General PracticeDivision of Primary Health Care80 Kennington RoadLondon SE11 6SPGreat Britain

Prof. Dr. H. KoopHELIOS Klinikum BerlinKlinikum BuchInnere Medizin IIHobrechtsfelder Chaussee 100D-13125 BerlinGermany

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Prof. Dr. H. KrammerII. Med. UniversitätsklinikUniversitätsklinikum MannheimTheodor-Kutzer-Ufer 1-3D-68167 MannheimGermany

PD Dr. M. KreisChirurgieKlinikum der UniversitätMünchen-GroßhadernMarchioninistr. 15D-81377 MünchenGermany

Prof. Dr. W. KruisEvang. Krankenhaus KalkInnere MedizinBuchforststr. 2D-51103 KölnGermany

Prof. Dr. A. LacyHospital Clinico y ProvincialUniversidad de BarcelonaDepartment of SurgeryVillarroel 170E-08036 BarcelonaSpain

Dr. G. LatellaUniversita di L'AquilaCattedra di GastroenterologiaVia S. Sisto 22 EI-67100 L'AquilaItaly

Prof. Dr. P. LayerIsraelitisches Krankenhausin HamburgInnere MedizinOrchideenstieg 14D-22297 HamburgGermany

Prof. Dr. B. LembckeSt. Barbara-HospitalInnere MedizinBarbarastr. 1D-45964 GladbeckGermany

Dr. J. LindsayThe Royal London HospitalEndoscopy UnitWhitechapelLondon E1 1BBGreat Britain

Dr. M. LukasCharles UniversityFirst Faculty of MedicineV Medical DepartmentU nemocnice 2CZ-128 08 PragueCzech Republic

Prof. Dr. P. MarteauHôpital EuropéenGeorges PompidouService d'Hépato-Gastroentérologie20, rue LeblancF-75908 ParisFrance

PD Dr. D. MeyerChirurgieKlinikum der Universität WürzburgJosef-Schneider-Str. 2D-97080 WürzburgGermany

PD Dr. H. MönnikesHepatologie/GastroenterologieCharité UniversitätsmedizinCampus Virchow-Klinikum (CVK)Augustenburger Platz 1D-13353 BerlinGermany

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Prof. Dr. J. MössnerUniversitätsklinikum LeipzigInnere Medizin IIPhilipp-Rosenthal-Str. 27D-04103 LeipzigGermany

Prof. Dr. J.M. MüllerAllgemein- und VisceralchirurgieCharité UniversitätsmedizinCampus Charité MitteSchumannstr. 20-21D-10117 BerlinGermany

Prof. Dr. E. NeugebauerChirurgieStädt. Krankenhaus Köln-MerheimKliniken der Stadt KölnOstmerheimer Str. 200D-51109 KölnGermany

Prof. Dr. D. ÖrtliMittlere Strasse 91CH-4012 BaselSwitzerland

Dr. M.Z. PanosEuroclinic9, Athanasiadou StreetGR-11 521 AthensGreece

Prof. Dr. S. PostKlinikum MannheimChirurgieTheodor-Kutzer-Ufer 1-3D-68167 MannheimGermany

Prof. Dr. E.M.M. QuigleyCork University HospitalDepartment of MedicineClinical Sciences BuildingWilton RoadCorkIreland

Prof. Dr. A. RevhaugUniversity Hospital of TromsøDepartment of SurgeryN-9038 TromsøNorway

Dr. S. SchanzEvang. Krankenhaus KalkInnere MedizinBuchforststr. 2D-51103 KölnGermany

Prof. Dr. J. SchölmerichKlinik füfr Innere Medizin IKlinikum der Universität RegensburgD-93042 RegensburgGermany

Prof. Dr. V. SchumpelickAllgemeinchirurgieUniversitätsklinikum AachenPauwelsstr. 30D-52074 AachenGermany

Prof. Dr. N. SenningerAllgemeine ChirurgieKlinikum der UniversitätWaldeyerstr. 1D-48149 MünsterGermany

Prof. Dr. R.C. SpillerUniversity HospitalQueen's Medical CentreDivision of GastroenterologyC Floor, South BlockNottingham NG7 2UHGreat Britain

Prof. Dr. M. StarlingerAllgemeine öffentlicheKrankenanstaltenChirurgische AbteilungSt. Veiter Str. 47A-9026 KlagenfurtAustria

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PD Dr. T. WedelAnatomieUniversitätsklinikum Schleswig-Holstein, Campus LübeckRatzeburger Allee 160D-23562 LübeckGermany

S.D. Wexner, M.D. Professor of MedicineCleveland Clinic FloridaDepartment of Colorectal Surgery2950 Cleveland Clinic BoulevardWeston, FL 33331USA

Prof. Dr. M. ZeitzMedizinische Klinik ICharité UniversitätsmedizinCampus Benjamin Franklin (CBF)Hindenburgdamm 30D-12203 BerlinGermany

Prof. Dr. H. ZirngiblHelios Klinikum WuppertalChirurgieHeusnerstr. 40D-42283 WuppertalGermany

POSTER ABSTRACTS

Poster Numbers 1 - 29

1Anorectal manometry in patients with left-sided diverticulosis

Poniewierka E, Blachut K, Kempinski RWroclaw Medical University, Wroclaw, Poland

Introduction: Colonic diverticulosis is a western civilization disease, with frequencyincreasing with age. Some of patients with diverticulosis suffer from chronic symptoms:abdominal pain, flatulence and abnormal bowel habit - especially constipation. Althoughcommon prevalence of diverticulosis its pathogenesis and cause of symptoms remainunclear. High intralumenal pressure and other motor disturbances in diverticular colonwere confirmed in many studies, but anorectal manometry has not been carefullyanalyzed.Aim of the study was evaluation of the anorectal manometry in patients with left-sidedcolonic diverticulosis and comparing those results to patients with: 1. primaryconstipation, 2. diverticulosis without change in bowel habit and 3. control group.

Methods: Patients were divided in 4 groups. Group 1 (n = 12) consisted of patients withleft-sided diverticulosis and constipation, group 2 (n = 10) consisted of patients withdiverticulosis without defecation abnormalities, group 3 (n = 18) consisted of patientswith primary constipation, and group 4 (n = 12) consisted of patients with normal bowelhabit. Anorectal manometry was performed using water perfused catheter with latexballoon. Manometric and volumetric data were assessed.

Results: In group 1 higher resting and squeeze pressures comparing with group 2, 3and control group were found: mean resting pressure 82.3; 61.4; 56.7; and 58.8 mmHgrespectively and mean squeeze pressure: 148.3; 110.3; 106.4; and 112.8 mmHgrespectively. We have not found statistically significant differences in volumetricexamination between studied groups.

Discussion/Conclusion: There is abnormal anorectal function in patients withsymptomatic left-sided diverticular disease in the form of high resting and squeezepressure in the anal canal.

2Colonic diverticulosis. Review of 435 cases from Lower Silesia inPoland

Katarzyna Blachut, Leszek ParadowskiDepartment of Gastroenterology and Hepatology, Wroclaw Medical University, Poland

Introduction: Diverticular disease occurs more often in Western Europe, the USA,Australia and Asian countries adopting western life style. Geographic variation concernsalso location of the divericula throughout the colon. The data from Eastern and MiddleEurope are still limited. Aim of the study was assessment of the incidence, distributionand clinical manifestation of the colonic diverticulosis.

Methods: Retrospective examination of the records of consecutive patients with colonicdiverticulosis hospitalized in Department of Gastroenterology and Hepatology ofWroclaw Medical University between 1999 and 2001 was performed. The study groupconsisted of 435 patients (mean age 65.1 years, range 31-90): 281 women (mean age65.1 years) and 154 men (mean age 65 years).

Results: Patients with diverticulosis constituted 9.5% of all patients hospitalized in thestudy period. 75% of patients was older than 60 years. In 33.6% of patients diverticulawere located in sigmoid colon, in 27.4% in sigmoid and descending colon, in 14.3% inwhole colon. The most often complaints were: abdominal pain (82.5%), irregulardefecation (constipation - 38.8%), flatulence (28.6%). Complications occurred in 12%of patients and included: diverticulitis (9%), bleeding (1.1%) and diverticular colitis(1.8%). The most common coexisting diseases were: arterial hypertension (37.7%),atheromatosis (26.9%), ischaemic heart disease (23.4%), degenerative joint disease(25.7%), overweight/obesity (59.8%), hypercholesterolaemia (67.2%).

Discussion/Conclusion: Diverticular disease is a significant problem in elderly patientswith most common occurrence in sigmoid and ascending colon. In almost 90% ofpatients diverticulosis was uncomplicated with clinical features of abdominal pain,irregular defecation, flatulence.

3Immediate colonoscopy followed by therapeutic barium enemaas highly effective and inexpensive management option fordiverticular bleeding

Blaut U., Marecik J., Gniady J., Ejma-Multanski J.Ludwik Rydygier Hospital, Cracow and Department of Pathophysiology, JagiellonianUniversity Medical School, Cracow, Poland

Introduction: Urgent colonoscopy has established value for diagnosis and treatmentof hematochezia. Recently barium enema has been rediscovered for therapy ofdiverticular bleeding. The aim of this study was to evaluate the efficacy of immediate colonoscopy followedby therapeutic barium enema in the management of diverticular bleeding.

Methods: Patients admitted to our hospital for significant rectal bleeding or in-patientsdeveloping such condition are prepared by enemas and undergo colonoscopy within 3 hours. Appropriate endoscopic treatment is applied when necessary. Sedation isavoided if possible. When diverticular bleeding or it's stigmata are recognized, patientreceives therapeutic barium enema beside standard conservative treatment.

Results: 124 urgent colonoscopies were performed for rectal bleeding in 2002 to 2004.Caecum was reached in 28 cases, in other the scope was introduced to the level wherelumen contained normally-looking stool or stenotic lesion was met. Mild sedation(midazolam + fentanyl) was necessary only in 7 cases. Diverticular bleeding wasdiagnosed in 46 patients (37%; 16 men, 30 women, 56-93 years old). Those patientsreceived barium enema, what resulted in persistent bleeding control in all but one case.This last was ICU patient in whom second episode occured 8 hours later. Colonoscopywas repeated, the bleeding site was detected and injected with epinephrine. 6 hourslater third episode occured and was definitely stopped with epinephrine injection andargon plasma coagulation.

Discussion/Conclusion: Our experience shows that immediate colonoscopy followedby therapeutic barium enema is highly effective and inexpensive management optionfor diverticular bleeding. Moreover no mortality or complications were observed.

4Perforated diverticulitis: Primary or secondary anastomosis?

Christoph Elsing, Marina Zivcec, Wilhelm Gross-WeegeDepartment of Visceral Medicine, St. Elisabeth Hospital Dorsten, Germany

Introduction: Surgical treatment of perforated diverticulitis has received controversialdiscussion during the past decade. Despite broad spectrum antibiotics there is stilldisagreement whether to resect the perforated sigmoid colon with a primaryanastomosis or to perform a two-stage procedure.

Results: We report a 61 year old female patient who suffered from lower left sidedabdominal pain for seven days and concomitant diarrhea. The patient had a BMI of 38,obesity stage II. At admission there was a slight tenderness in the left lower abdomen.Laboratory values showed systemic signs of inflammation with WBC of 13.600/:l anda C-reactive protein level of 46.7 mg/dL. X-ray's revealed free abdominal air, CT-scanin addition a thickened sigmoid wall. The diagnosis of perforated diverticulitis was made.Due to the limited clinical symptoms with only minor signs of peritonitis a conservativetreatment approach was initiated. The patient received i.v. antibiotics and fluid and waskept on liquid oral intake. Daily examinations were performed. After 10 days, thesystemic inflammation setteled and the operation was done. The inflammed colonicsegment was resected and a primary anastomosis was established. The postoperativecourse was uneventfull and the patient discharged ten days later.

Discussion/Conclusion: Our case shows, that in selected patients, where a two stepprocedure with colostomy might be technical difficult (high BMI), a primary conservativeapproach with carefull examinations is possible. Consecutive, a single step sigmoidalresection can be performed without risk. The treatment approach of patients withperforated diverticulitis should include all aspects of the patient and a strict two stepoperation protocol should be avoided.

5Is colonic diverticulosis a risk factor for colorectal tumors?

O. Fratila, A. Lenghel, A. Maghiar2nd Medical Clinic, University of Oradea, Romania

Introduction: Diverticulosis and colorectal tumors seems to share similar epidemiol-ogical features and risk factors.

Aim: To evaluate a possible association between colonic diverticulosis and both polypsand colorectal cancer in patients undergoing total colonoscopy.

Methods: Between January 2000 - December 2004 lower endoscopies were performedin 2184 patients in our endoscopy unit. We studied the prevalence of the diverticulosisand the association of the diverticulosis with polyps and colorectal cancer.

Results: 190 (8.7%) cases (mean age 62 plus/minus 14 years) had diverticulosis of thecolon, 101 (53.1%) men and 89 (46.9%) women. In 174 (91.6%) patients was affectedthe left side of the colon, 4 (2.1%) cases had caecal diverticulosis and 12 (6.3%) caseshad diverticulosis on the entire colon. Polyps were found in 51 (26.8%) patients withdiverticulosis and in 569 (28.5%) patients without [p = ns]. The prevalence of polypslocated in the left colon was significantly higher in patients with diverticula than incontrols (62.1% vs. 38.6%; p < 0.05). Colorectal cancer prevalence was similar inpatients with and without diverticula (5.7% vs. 7.1%; p = ns), and no difference wasdetected regarding localization.

Discussion/Conclusion: Patients with colonic diverticulosis have a higher risk ofpresenting polyps in the left colon. This observation could be important in the screeningand surveillance programmes for colorectal cancer.

6Escherichia coli Nissle 1917 (ECN) prolongs remission insymptomatic uncomplicated diverticular disease of the colon

P Fric, M ZavoralDepartment of Medicine, 1st Faculty of Medicine and Central Army Hospital,Postgraduate Institute of Medicine, Prague, Czech Republic

Introduction: The effect of probiotics in symptomatic uncomplicated diverticular diseaseof the colon remains largely unknown.

Methods: 15 subjects (5 males, 10 females) aged 68-91 years (average 74.8 years)presented with abdominal pain, irregular defecation, bloating and excessive flatulance.Diagnosis was established with colonoscopy, double-contrast barium enema or both.Treatment (T1) with an intestinal antimicrobial (dichlorchinolinol) and adsorbent (activecoal tablets) was compared with the same set-up supplemented with ECN (T2) in aprospective open study. The T1 regimen was applied for 1 week. In the T2 regimen, theapplication of ECN strain (Mutaflor® capsules, 2.5 x 1010 viable microbiota/capsule,Ardeypharm, Herdecke, Germany) followed immediately after T1 for an average of 5.2weeks. The lengths of two successive remissions with the T1 set-up were comparedwith the length of remission after T2. The intensity of symptoms before and afteradministration of the probiotic was also evaluated.

Results: The lengths of two successive remissions after T1 amounted to 2.66 and 2.20months (average 2.43 months). The average length of remission after T2 was 14.1months (P < 0.001). All symptoms after T2 decreased significantly (P < 0.001).

Discussion/Conclusion: Non-pathogenic Escherichia coli Nissle 1917 significantlyprolonged the remission period and improved the abdominal syndrome in symptomaticuncomplicated diverticular disease.

7Urgent surgery for complicated colonic diverticula

G. Funariu, V. Bintintan, R. Seicean, 1st Surgical Clinic, Cluj-Napoca, Romania

Introduction: Acute complications of colonic diverticula requiring urgent operation,encountered in 15% to 20% of cases, pose serious diagnostic and surgical problems.The aim of this retrospective study was to discuss the emergency surgical treatment oflife threatening complications of colonic diverticula.

Methods: In the last 11 years 22 of 101 patients with colonic diverticula (22.1%)underwent urgent surgery for acute complications: perforated gangrenous diverticulitiswith generalized peritonitis (n = 8) or pericolic abscess (n = 8), acute bowel obstruction(n = 4) and severe diverticular bleeding (n = 2). In all patients with diffuse peritonitis oracute obstruction the indication for surgery was decided on clinical basis, thecomplicated diverticula being recognized only intraoperatively.

Results: Emergency surgical strategy was differentiated according to the type ofcomplication and the biologic condition of the patient: segmental colectomy and primaryanastomosis (n = 9) for diverticular perforation (n = 4), colonic stenosis (n = 3) ordiverticular bleeding (n = 2); Hartmann's resection with late reconnecting anastomosisin patients with diverticular perforation (n = 5) or colonic obstruction (n = 1);diverticulectomy with protective colostomy (n = 2) and colostomy and/or drainage andsecondary colectomy (n = 5) for diverticular perforations in patients with poor generalcondition. Only one patient (4.5%) died postoperatively of multiple organ failure due togeneralized peritonitis. There was no anastomotic leakage in patients with primaryanastomosis. Six patients (27.2%) developed wound infection. Hospital stay rangedbetween 11 and 60 days, being longer for patients with two-stage operation

Discussion/Conclusion: Primary colectomy with immediate or delayed anastomosisis the best surgical procedure for acute diverticular complications in patients with goodbiologic status. Two-stage operations such as colostomy or drainage coupled with latecolectomy remain the viable alternative in patients with advanced disease and criticalbiologic condition

8Experience of treatment of diverticulitis

Gaponov I., Gaponov V., Shevtsova Z.*Medical Academy, Institute of Gastroenterology AMS*, Dnipropetrovsk, Ukraine

Purpose: To study peculiarities of clinical course of diverticulitis and to improve resultsof treatment.

Methodology: 87 patients with diverticular disease (age from 42 to 80 years, 37 males,50 females) were under observation. Clinical peculiarities of diverticulitis were studied.Endoscopic, morphological, biochemical, X-ray, ultrasonic, microbiological investigationswere carried out. Standards of treatment of diverticular disease and complications wereproposed. Conservative treatment of diverticulitis included Salofalk® (tablets,suppositories, enemas), antibiotics, spasmolytics. Salofalk® was injected by usingspecial-made syringe for endoscopic manipulations. Surgical methods (resection ofcolon) in patients with complications was performed. Secondary prophylaxis ofdiverticulosis was developed.

Results: In patients diverticulas were located in sigmoid in 59.8% cases, in the left sideof colon - 34.5%, in other parts of colon - 5.7%. Multiple diverticulas were observed in58 patients. Diverticulitis occurred in 40 patients (46%) with diverticular disease. Clinicalsymptoms of diverticulitis were: abdominal cramp-like pain, bloated abdomen, irregularbowel habits, fever. Blood tests were leukocytosis, raised erythrocyte sedimentationrate. 21 patients had complications such as bleeding (10 patients), perforation (5),abscess formation (4), stenosis (2). Bleeding of I-II degrees was stopped by usingconservative method. Stop of bleeding and course of inflammatory process inprotrusions were controlled by colonoscopy. Operative method was used in patients withbleeding of III-IV degrees. Before, during and after operation combinations of antibiotics(dalacin+amikin, abaktal+amoxiclav, metronidazol+claforan) were used. It decreasesfrequency of postoperative complications. In postoperative period with the purpose ofsecondary prophylaxis of diverticulosis high-fiber diet, Mucofalk®, probiotics,prokynetics, lactose were administered.

Conclusions:1. Developed standards of treatment of diverticulitis decreases frequency of

complications. 2. Method of operative treatment depends upon localization of protrusions, length of

process and character of complications. 3. In postoperative period it's necessary to hold secondary prophylaxis of

diverticulosis.

9Peculiarities of forming of diverticulas in experiment and treatingof diverticular disease in clinic

Gaponov V., Gaponov I., Shevtsova Z.*Medical Academy, Institute of Gastroenterology AMS*, Dnipropetrovsk, Ukraine

Purpose: To study peculiarities of changes in diverticular-like protrusions in the colonwall in experiment and to improve treatment methods of patients with diverticulardisease.

Methodology: In experiment 83 diverticular-like protrusions in the colon wall of 8 dogswere made up by means of operations and metal foreign bodies were introduced thereinper rectum. To fix them up protrusion mouth was narrowed by serous muscular seams.Morphological changes in diverticular-like protrusions were studied. Aerococca throughdigestive tract lumen were introduced into 168 laboratory animals with injuries ofalimentary canal mucous layer and without injuries. At different times after introducingthe suspension of microorganisms into the digestive tract lumen, blood and viscera wereinoculated on the indicatory medium. Ways of aerococca penetration into vesselchannel were investigated.In clinic 87 patients with diverticular disease were under observation. Complextreatment included Mucofalk®, which helped to normalize defecation and lesseneddyspepsia. In case of diverticulitis Salofalk® and antibiotics were given for 10-14 days.

Results: With experimental animals morphological investigations showed colon wallinflammation reaction of various degrees. After 10 days from the beginning of theexperiment there took place round-cell infiltration of mucous and submucous layers,oedema of tissues and mucosa necrosis in some places of diverticular-like protrusions.Destructive inflammatory alterations in protrusion wall stayed during one month and insome cases spread over onto neighboring tissues. Multiples infusion of microorganismsinto laboratory animals with injuries of alimentary canal mucous layer resulted incontamination of the whole body. That confirms to barrier dysfunction of colon.In clinic complications of diverticulosis (diverticulitis, perforations, bleeding, fistulas,abscesses) were found in 61 patients. Before, during and after the operation (resectionof colon) the standard of treatment included antibiotics.

Conclusions:1. Inflammatory alterations in diverticular-like protrusions were prolonged, spreading

alterations onto neighboring tissues.2. The change of colon barrier function is of importance in development of

diverticulitis and their complications. 3. The use of antiinflammatory treatment (Salofalk®, antibiotics) before and after the

operation improves results of treatment and quality of patients' life.

10Malabsorption syndrome in jejunal diverticulosis

V. Gerova, S. Stoinov, H. Kadyan, E. PiriovaClinical Center of Gastroenterology, University Hospital "Queen Joanna", Sofia, Bulgaria

Small bowel diverticulosis is a rare disease of gastrointestinal tract that occurs mostfrequently in older patients. There is evidence to suggest that this entity is a result ofsmall bowel motor dysfunction. Diverticula of the small bowel are usually asymptomaticbut occasionally can present with serious complications.We report a case of jejunal diverticulosis in a 39-year-old man with previouslyunexplained abdominal discomfort accompanied by intermittent diarrhea who presentedwith symptoms and biochemical data of malabsorption: diarrhea (over 10/24h) andsteatorrhea, expressive weight loss, progressive fatigue and low serum levels ofhemoglobin (95 g/l), total protein (40 g/l), potassium (1.66 mEq/l), calcium (1.06 mEq/l),blood sugar (3.0 mmol/l). Elevated fasting hydrogen breath levels after ingestion oflactulose indicated small bacterial overgrowth. Microbiological studies of the fecesrecovered E.coli, Proteus, Klebsiella, Candida spp. An X-ray series of the small boweldetected multiple large jejunal diverticula. The adequate therapy with antibiotics(quinolones, metronidazole, amphotericin B), probiotics, pancreatic enzymes,supplementation of albumin, vitamins, electrolytes and fluids failed to provideimprovement of refractory malabsorption's symptoms and patient dyed due tomultiorgan failure. It is interestly the presence of small intestinal diverticula in anothermember of the patient's family who dyed during second laparotomy for small bowelobstruction. Small bowel diverticulosis should not be regarded as a rare, incidental and inconse-quential finding.

Address for correspondence:

Dr. Vania Gerova Clinical Center of Gastroenterology8 str. Belo moreBG-1527 Sofia BulgariaE-mail: vanger@hotmail.com

11Incidence of colonic diverticulosis in patients with significantsymptoms of lower gastrointestinal tract disease

Gniady J., Marecik J., Blaut U., Ejma-Multanski J.Ludwik Rydygier Hospital, Cracow and Department of Pathophysiology, JagiellonianUniversity Medical School, Cracow, Poland

Introduction: The aim of this study was to estimate incidence of diverticulosis inpatients undergoing colonoscopy for significant symptoms of lower gastrointestinal tractdisease and coexistence with other diseases.

Methods: The records describing colonoscopies performed in our center during last 2years (2003 -2004) were searched to identified patients with colonic diverticula.Procedural and demographic data was collected and analyzed.

Results: 2308 procedures were perfomed. Colonic diverticula were detected in 560patients (24,26 %) of age between 32 and 99 years (mean 68,54 ± 10,53). 264 weremale and 296 female. The age in both groups was similar (68,84 vs. 68,25 respectively).445 patients was older than 60 years. In 32 patients diverticula caused lowergastrointestinal bleeding what was diagnosed during urgent colonoscopy (bleedingdiverticulas of it's stigmata were seen). In 157 patients polyps were detectedcoincidentally with diverticula. In 57 patients multiple adenomatous polyps were found.28 patients had polyps bigger than 10 mm in diameter and 10 of them had 20 mm ormore. 34 patients were diagnosed with coexisting neoplastic tumours, 9 - inflammatorychanges of diffrent etiology and 5 with angiodysplastic lesions. What interesting - colitisulcerosa or Crohn disease never coexisted with diverticulosis.

Discussion/Conclusion: Colonic diverticulosis is a common condition causingsignificant abdominal manifestations. There is no difference between male and femalepatients. In patients with diverticular disease adenomatous polyps are offenlyrecognised. Therefore radiologic examination which is most sufficient in diverticulardisease cannot be regarded as the end of diagnostic work-up but should be followed orreplaced by endoscopic examination.

12Are nonsteroidal anti-inflammatory drugs (NSAID) and Aspirin arisk factor for diverticular bleeding?

A. Goldis, V. Lungu, R. Goldis, C. Vernic, D. LazarGastroenterology Dept. University of Medicine Timisoara, Romania

Introduction: Bleeding from colonic diverticula occurs relatively frequent in patients withdiverticulosis. In this prospective study we investigated the influence of NSAID or Aspirinconsumption on diverticular bleeding.

Methods: All patients that underwent colonoscopy in our unit in a 18 months periodwere questioned about NSAID and Aspirin consumption. We investigated a total of 1627colonoscopies (913 female, 714 male), with the mean age of 51.2 years (range 17-89years).

Results: 314 (19,29%) of the 1627 investigated patients presented diverticulosis and43 of them (13.7%) had previous episodes of diverticular bleeding. 37 (86.04%) of thesubjects with diverticular bleeding used NSAID or Aspirin, and from the non-bleedinggroup only 81 (29.88%) were NSAID or Aspirin users (p < 0.01 - Chi-square test).

Discussion/Conclusion: In our study, the use of NSAID or Aspirin increasedsignificantly the risk of bleeding of colonic diverticula (p < 0.01).

13Treatment of acute complicated diverticulitis - Hartmann'sprocedure can be reduced to less than 50%!

T. Herzog, U. Mittelkötter, D. Weyhe, Ch. Müller, W. UhlSt. Josef-Hospital Bochum, Chirurgische Klinik, Klinikum der Ruhr-Universität,Gudrunstr. 56, 44791 Bochum, Germany

Introduction: Diverticular disease of the colon is a common condition in developedcountries. Prevalence increases with age. Most patients with diverticulosis will remainasymptomatic. 20-30% of patients presenting with acute diverticulitis will developpotentially life threatening complications like perforation, abscess formation, fistula, ileusor bleeding. The most frequent procedure in urgent surgery is a two stage interventionwith interval colostomy. This leads to high complication rates and coasts. Therefore acritical evaluation of surgical treatment options is necessary.

Patients and results: From January 2004 to March 2005 63 patients underwentsurgical resection for diverticular disease at our department. 29 (46%) patients neededurgent surgery. Despite non- elective surgical intervention a primary colorectalanastomosis was performed in 14 (48%) cases. 6 patients had protection by divertingileostomy, one patient received proximal diverting colostomy. In the other group weperformed the classic Hartmann procedure. Postoperative morbidity and mortality washigher for patients with colostomy. Furthermore there was a longer need forhospitalisation. Major surgical complications like anostomotic leak or sepsis were seenin 2 patients (14%) with primary colorectal anastomosis, compared to 7 cases (46%) inthe Hartmann group. Mortality was 27% (4/15) in the Hartmann group, whereas allpatients in the other group survived (0/14). Hospital stay was 35 days with colostomyvs. 17 days with direct colorectal anastomosis.

Conclusion: In urgent surgery for complicated diverticulitis it is possible to avoid classictwo stage operation with interval colostomy in 50%. Instead a direct colorectalanastomosis is feasible. Anastomosis protection can be achieved by creation ofdiverting ileostomy. This technique reduces the need for further surgical interventionsand reduces hospital stay, morbidity, coasts and complication rate. Instead quality of lifeincreases without colostomy. Today better treatment options in intensive care allow adifferentiated surgical treatment with modification of the standard procedure.

14Silent bowel perforation during colonoscopy in patients withextensive left-sided diverticular disease

J.A. Karagiannis, N. Mathou, K.D. ParaskevaGastroenterology Unit, "Agia Olga" Hospital, Athens, Greece

Introduction: Colonoscopy is the examination of choice for the investigation of a greatvariety of gastrointestinal symptoms and is considered as a very safe procedure withan overall perforation rate of about 0.1%. Several predisposing factors (mainly colonicinflammation with or without colonic dilatation and looping in the sigmoid colon) havebeen implicated for this complication which is related with significant morbidity and evenmortality. Diverticulosis and, mainly, diverticulitis are accompanied by both of the abovefactors. Pain during colonoscopy has been shown to be most commonly associated withlooping (90%), especially in the sigmoid colon (56%), and its intensity has been shownto correlate with the incidence of bowel perforation.Aim of the study was to investigate the incidence and severity of pain in patients withextensive left-sided diverticular disease who underwent diagnostic colonoscopy and inwhom bowel perforation eventually occurred.

Methods: 2357 elective diagnostic colonoscopies (1217 male, 1140 female, age range18-94 years) performed in a three years period (2002-2004) for the investigation eitherof various lower GI symptoms or anemia. All patients had standard prior bowelpreparation with premedication (spasmolytics in all plus midazolam adjusted to age orcontraindications) and all colonoscopies were performed by the same experiencedendoscopists.

Results: All procedures were completed uneventfully and clinical and/or biochemicalsigns (abdominal pain, lack of enteric sounds, high WBC) indicative of possible bowelperforation occurred either soon after or up to 36h after the procedure. 6 cases of bowelperforation were documented (0.25%) in total (plain abdominal x-ray and/or abdominalCT scan). 5/6 (83%) cases occurred in patients with extensive left-sided (sigmoid and/ordescending colon) diverticular disease out of 351 (1.4%), and 1/6 (16%) out of the rest2006 (0.04%) in a patient with infectious colitis. Endoscopic signs of diverticulitis werepresent in 1/5 (20%) patients. Pain during colonoscopy was either mild or absent in all5 patients with diverticular disease regardless of age, premedication given or finaldiagnosis relating to the reason of colonoscopy (diverticular disease or other) while thepatient with infectious colitis experienced considerable pain during the procedure. 4/6patients were treated conservatively and 2/6 (both with diverticular disease) had to beoperated.

Discussion/Conclusion: Perforation rate is considerably higher in patients withextensive left-sided diverticular disease and it must seriously taken into account thatsevere pain during the procedure, indicative of possible bowel perforation, is quiteuncommon.

15The operative procedure has no influence on long-term quality oflife after laparoscopic and open sigmoid resection - A matched-pairs analysis

M.S. Kasparek1, E. Schiele1, G. Seitz2, A. Koenigsrainer1, M.E. Kreis3

1University of Tuebingen, Department of General Surgery2University of Tuebingen, Department of Paediatric Surgery3University of Munich/Grosshadern, Department of General Surgery

Introduction: Sigmoid resections are increasingly often carried out laparoscopically.Aim of this study was to investigate, whether there is a difference in long-term qualityof life in patients after open and laparoscopic sigmoid resection.

Methods: Laparoscopic sigmoid resection was performed in 26 patients for recurrentdiverticulitis and in 8 patients with colonic cancer (17m, 18f; median age 59; range38-89; follow-up 54.8 months). Patients after open sigmoid resection served as acontrol. The gastrointestinal quality of life index was sent to each patient and theircontrols. 46 of the 68 questionnaires could be evaluated.

Results: Operating time was longer (171 ± 8 vs.128 ± 5 minutes; p < 0.05) andpostoperative hospital stay was shorter in the laparoscopic group (7 ± 0.4 vs.11 ± 1days; p < 0.05). No major complications occurred in either group, but minorcomplications occurred more frequently in the open group (53% vs.11%; p < 0.05).Quality of life was similar after open and laparoscopic resection if the procedure wasperformed for recurrent diverticulitis (95.0 ± 9.3 vs. 94.6 ± 8.1; n.s.) or for colonic cancer(106 ± 11.2 vs.113.6 ± 9.8; n.s.)

Discussion/Conclusion: Although time of hospitalisation and the frequency of minorcomplications are decreased after laparoscopic sigmoid resection, the procedure itselfseems to have a minor influence on long-term quality of life.

16Our strategy for treatment of diverticular disease and perforationcomplications (1982-2004)

Zs. Kincses, P. Bodrogi, I. Bartha1st Department of Surgery, University of Debrecen, Hungary

Introduction: The frequency of colonic diverticula rises with age. Approximately 30-35%of all people develop diverticular disease by the age of 60. Data from Europe and theUnited States suggest that diverticular disease involves the sigmoid and descendingcolon in 90% of the cases. The rate of inflammatory complications is 30%.

Methods: Between 1982 and 2004, 101 patients were operated on diverticular diseaseat the 1st Department of Surgery, University of Debrecen. The mean age of patientswas 62.9 years; the male/female ratio being 50:50. In 84 cases emergency operationwas performed, the remaining 17 underwent elective surgery. There were no majorcomplications recorded after elective interventions, the mortality rate turned out to be7.7%. These patients were over 80 years old, often with severe fecal peritonitis, whilein one patient a malignant tumor was found during surgery.

Results: Postoperative complication developed in 21 patients after acute operation. Themortality and complication rate was relatively high in cases of perforated left colondiverticula. According to the relevant literature, one-stage surgery in acute casesdecreases the frequency of postoperative complications and the mortality rate, but itcannot be performed under all circumstances.

Discussion/Conclusion: We used two-stage intervention (Hartmann's procedure) forall the patients. We believe that a scheduled reconstructive surgery after any necessaryconservative treatment and an appropriate time period results in complete recovery.Two-three annual inflammatory episode necessitates elective surgery.

17The safety of resection and primary anastomosis in perforateddiverticular disease

J. Lind; C. Bicknell; M. Petrou; D. Owen; N. Tomns; R. Harrison; I. Mitchell; C. Elton; P.MathurDepartment of Gastrointestinal Surgery, Barnet Hospital, London, UK

Introduction: The surgical management of left colonic perforations remainscontroversial. Commonly Hartmann's procedure is performed but there is increasingevidence that resection and primary anastomosis (RPA) is as safe. Our aim was toassess the safety of RPA for left colonic perforations.

Methods: Patients who underwent emergency colonic surgery (January 2002 -December 2004) were identified from theatre and electronic patient records. Of 118patients, 16 underwent RPA. Patients underwent preoperative CT scans to aid/confirmdiagnosis and proceeded straight to laparotomy for peritonitis.

Results: Male: female ratio was 10:6. Median age was 67 years (range 39-85 years).Peritonitis was secondary to diverticular perforation in 13 patients, stercoral perforationin 2 and ischaemic stricture in 1. There was associated paracolic abscess in 4. Fivepatients underwent left hemicolectomy, 5 anterior resection (1 with defunctioningileostomy) and 6 sigmoid colectomy (2 with defunctioning ileostomies). All hadintravenous antibiotics on induction. None had on-table colonic lavage. 11 anastomoseswere stapled and 5 hand-sewn. Median hospital stay was 15 days (7-28 days). Overallmorbidity rate was 56%. Early complications were 4 mild wound infections, 2 cases ofdiarrhoea, 1 urinary tract infection, 1 urinary retention, 1 deep vein thrombosis and 1subclinical anastomotic leak. Late complications were 2 incisional hernias around stomasites. The mortality rate was 0%.

Discussion/Conclusion: In our experience resection and primary anastomosis is safefor left sided colonic perforations, with mortality and morbidity rates comparable to thosepublished for Hartmann's procedure. We believe RPA should be considered in selectedcases of left colonic perforation.

18Timing and outcome of surgery in diverticular disease

D. Mercut, G. Ianosi, D. Neagoe, F. Racanel, M. Calbureanu-Popescu, V.TomaUniversity of Medicine and Pharmacy, Craiova, Romania

Introduction: Diverticular disease of the colon has been recorded with increasingfrequency, predominantly affecting the left colon. About one third of patients will developpotentially life-threatening complications including hemorrhage, perforation, fistulae,stricture or obstruction. The aim of this study is to evaluate surgical results in patientswith complicated diverticular disease according to the stage of disease, surgicaltechnique, postoperative complications and mortality.

Methods: We achieved 100 patients admitted in surgical clinic during the period 1998- 2004. We analyzed the cause of admission, modality of admission (emergency orelective), medical history, and post-operative morbidity and mortality related to surgicaltechnique.

Results: Forty-one patients were transferred from gastroenterological clinic for electivecolectomy and 59 patients were admitted in emergency for a complication of diverticulardisease. In emergency we performed especially Hartmann's procedure (52 cases) butin case of elective surgery segmentary resection with anastomosis (eventually protectedby a covering colostomy) dominates the surgical technique (36 cases). Morbidity was28% (21 cases in emergency and 7 in elective surgery) and mortality was 16% (allcases from emergency group).

Discussion/Conclusion:1. Emergency surgery should be prevented adapting treatment to risk factors for

complicate disease, including factors derived from the socioeconomic medium ofthe patients.

2. Colon resection with immediate anastomosis is the operation of choice when localconditions permitted but Hartmann's procedure is, still, a valid option especially foremergency cases.

19Clinical course and outcome of conservative treatment inpatients with diverticulitis of the sigmoid colon

M.H. Müller1, J. Glatzle2, M.S. Kasparek2, M.E. Kreis1

Department of Surgery, Ludwig-Maximillians-University Munich-Grosshadern,Germany1, Department of General Surgery, University of Tuebingen, Germany2

Introduction: The indication for elective surgery following conservative treatment ofacute diverticulitis is still under debate. This is partly due to limited data on the outcomeof conservative management in the long run. We, therefore, aimed to determine thelong-term results of conservative treatment for acute diverticulitis.

Methods: The records of all patients treated at our institution for diverticulitis between1985 and 1991 were reviewed (n = 363; median age 64 years; range 29-93). Patientswho received conservative treatment were interviewed 1996 and 2002 (follow-up time7 years, 2 months (range 58-127 months) and 13 years, 4 months (range 130-196months)).

Results: 252 (69 %) of the patients were treated conservatively, while 111 (31%) wereoperated. At the 1st follow-up, 85 of the patients treated conservatively had died, oneof them from bleeding diverticula. Recurrence of symptoms was reported by 78 of theremaining 167 patients and 13 underwent sugery. At the 2nd follow-up, one patient haddied from sepsis following perforation during another episode of diverticulitis. 31 of the85 interviewed patients reported symptoms and 12 had been operated. In summary, atthe 2nd follow-up interview, 34 % of the patients treated initially had had a recurrenceand 10 % had undergone surgery. No predictive factors for recurrence of symptoms orlater surgery could be determined.

Discussion/Conclusion: Despite a high rate of recurrences following conservativetreatment of acute diverticulitis, lethal complications are rare. Thus, surgery shouldmainly be undertaken to achieve relief of symptoms rather than to prevent death fromcomplications.

20Differential or comorbidity diagnosis - A case report

Ovidiu Petrascu1, Adrian Boicean1, Mircea Deac1, Aurel Coman2

1Department of Internal Medicine, 2Department of Surgery, University of Sibiu, Romania

Both colonic diverticular disease and colonic cancer may share a number ofepidemiological characteristics (increased incidence, occurrence in elderly persons andthe localization predominantly on the level of the left colon. The diseases may alsoshare some clinical manifestations such as abdominal pain, altered bowel habits orrectal bleeding. In some cases, anemia and rectal bleeding are responsible for triggeringthe diagnosis algorithm in the case of both the diverticular disease and of colorectalcancer.

We present the case of a 79 year-old patient, who was diagnosed with colonicdiverticular disease at the age of 77. Two years after the diagnosis, the patient wasadmitted for repeated rectal bleeding, distinct fatigue and intense pallor on the level ofthe skin and the mucous membrane. Biological examinations indicated severe anemia(Hb = 5.5 g/dl, Ht = 18%), microcytosis and hypochromia of the eritrocytes,hyposideremia (serum iron = 13.9 g/dl), moderate leukocytes and light thrombocytosis.

Barium enema showed many diverticular images on the sigmoidian and descendingsegment level, and, on the level of the ascending colon, under the hepatic flexion, theexistence of a proliferative process with peritumoral invasion. Colonoscopy confirmedthe ascending colon tumor and abdominal CT scan indicated small retroperitonealadenopathies without secondary hepatic determination images, as well as a largercecum. After surgery for ascending colon tumor, the patient's evolution was positive.

The evolution of this particular case makes us wonder whether repeated rectal bleedingand severe iron deficiency anemia may put us on the alert about the clinical picture ofcolonic diverticular disease, if we consider the fact that a limited number of colonicdiverticular disease cases have these clinical elements. Also, we should not overlookthe fact that, at times, colorectal cancer may become, from the most importantdifferential diagnosis, a morbid association in the evolution of colonic diverticulardisease.

21Surgical therapy for right-sided diverticular disease: Results ofa prospective study

O. Schwandner, P. Hildebrand, S. Farke, H.-P. BruchUniversity Clinic Schleswig-Holstein, Campus Lübeck, Germany

Introduction: Left-sided diverticulitis is a common disease in Western countries,whereas right-sided diverticultitis is rare and symptoms are often similar to the clinicalsigns of an acute appendicitis. It was the aim of this study to analyse surgicalexperience in right-sided diverticulitis.

Methods: All patients who underwent resectional surgery for both right-sided andsigmoid diverticular disease were entered prospectively in a registry database (8-yearobservation period, 1996-2003). For the current study, a retrospective analysis of allpatients who underwent ileocolic resection or right colectomy for right-sided colonicdiverticulitis was performed, specifically focussing on incidence, clinical symptoms,indication for surgery, type of procedure, and histopathological parameters includingimmunohistochemistry, and outcome in right-sided diverticulitis.

Results: Within 8 years, 481 patients were treated surgically for chronically recurrentor acute complicated diverticular disease: 468 patients with sigmoid diverticulitis, 12patients with right-sided diverticulitis, and 1 patient with combined right-sided andsigmoid diverticular disease. This corresponds to an incidence of right-sided diverticulitisof 2.5% related to the total number of resections for diverticulitis, and an incidence of1.3% in relation to the appendectomies in our patients. In 4 patients, acute appendicitiswas presumed preoperatively. Most common diagnostic tool was ultrasonography. Rightcolectomy was performed in 9 patients with complicated cecal diverticulitis, whereasileocolic resection was performed in 2 patients and simultaneous ileocolic and sigmoidresection was carried out in one patient. Postoperatively, no morbidity occurred.Histopathological assessment showed local perforation in 75% (9/12). Hypoganglionosisor aganglionosis was detected in 5 of 12 resected specimen.

Discussion/Conclusion: As right-sided diverticulitis is a rare colonic disease inWestern countries, the differentiation from acute appendicitis can be difficult. In general,there is no difference in the treatment of right-sided diverticulitis compared to left-sideddiverticulitis, and resectional surgery is only indicated in complicated right-sideddiverticulitis. Resection of the inflamed colon with primary anastomosis is safe and canbe performed by laparoscopy in experienced centers. At present, it can only bespeculated whether hypoganglionosis or aganglionosis are causative factors in theetiology of right-sided diverticulitis.

22Laparoscopic colectomy for diverticulitis is not associated withincreased morbidity when compared to non-diverticular disease

O. Schwandner, S. Farke, H.-P. BruchUniversity Clinic Schleswig-Holstein, Campus Lübeck, Germany

Introduction: It was the aim of this prospective study to compare the outcome oflaparoscopic sigmoid and anterior resection for diverticulitis and non-diverticulardisease.

Methods: All patients who underwent laparoscopic colectomy for benign and malignantdisease within a 10-year period were entered into the prospective PC database registry.For outcome analysis, patients who underwent laparoscopic sigmoid and anteriorresection for diverticular disease were compared to patients who underwent the sameoperation for non-inflammatory (non-diverticular) disease. The parameters analyzedincluded age, gender, comorbid conditions, diagnosis, procedure, duration of surgery,transfusion requirements, conversion, morbidity including major (requiring reoperation),minor (conservative treatment) and late-onset (post-discharge) complications, stay onICU, hospitalization, and mortality. For objective evaluation, only laparoscopicallycompleted procedures were analyzed. Statistics included Student`s t-test andchi-squared analysis (p < 0.05 statistically significant).

Results: A total of 676 patients were evaluated including 363 with diverticular diseaseand 313 with non-inflammatory disease. There were no significant differences inconversion rates (6.6% vs. 7.3%, p > 0.05), so that laparoscopic completion rate was93.4% (n = 339) in the divertivculitis group and 92.7% (n = 290) in the non-diverticulitisgroup. Both groups did not significantly differ between age or the presence of comorbidconditions (p > 0.05). In the diverticulitis group, recurrent diverticulitis (58.4%) andcomplicated diverticulitis (27.7%) were most common indications, whereas, in thenon-diverticulitis group, outlet obstruction by sigmoidoceles (30.0%) and cancer (32.4%)were the main indications. Most common procedure was laparoscopic sigmoidresection, followed by sigmoid resection with rectopexy and anterior resection. Nosignificant differences were documented for major complications (7.4% vs. 7.9%), minorcomplications (11.5% vs. 14.5%), late-onset complications (3.0% vs. 3.5%),reoperations (8.6% vs. 9.3%) or mortality (0.6% vs. 0.7%) between the two groups(p>0.05). In the postoperative course, no differences were noted in terms of stay onICU, postoperative ileus, parenteral analgesics, oral feeding and length ofhospitalization (p > 0.05).

Discussion/Conclusion: These data indicate that laparoscopic sigmoid and anteriorresection can be performed with acceptable morbidity and mortality for both diverticulardisease and non-diverticular disease. The results show in particular that laparoscopicresection for inflammation is not associated with increased morbidity.

23Cyclic rifaximin treatment in uncomplicated colonic diverticulardisease - Results of an open study

Simon L., Salamon Á.Tolna County Hospital, Dept. of Gastroenterology, Szekszárd, Hungary

Introduction: Aquired diverticular disease of the colon is extremely common indeveloped countries. Poorly absorbable antibiotics may have favourable results inlong-term treatment. An open study was conducted to evaluate the efficiency of rifaximinin prevention of complaints and recurrent diverticulitis.

Methods: 30 patients with known were elected to receive rifaximin 200 mg bid for thefirst six days of every month, for 6 months. High-fibre diet was proposed. Basiclaboratory studies ( WBC, sedimentation rate and CRP) were performed . Patients werereviewed on a monthly basis by clinical examinations: changes in symptom variables(lower abdominal pain, upper abdominal pain, bloating, tenesmus, diarrhea, abdominaltenderness) were evaluated on a 10-points Visual Analogue Scale (VAS), and presenceof acute diverticulitis (abdominal mass, fever, US) was excluded by every month visits.

Results: All of 30 included patients completed the study. After 6 months of cyclicrifaximin treatment 83 % of patients showed lower global symptomatic score incomparison with the time of inclusion. Acute diverticulitis, other complication or sideeffects were not observed. Most effective self-controlled improvement was mentionedregarding lower abdominal pain, tenesmus, bloating and abdominal tenderness. Initiallyelevated CRP and ESR levels were diminished in five cases, and remained normal inthe others.

Discussion/Conclusion: Cyclic administration of relative low dose rifaximin inuncomplicated colonic diverticular disease resulted in reducing abdominal complaintsand prevention recurrent diverticulitis. This effect probably may be explained byreduction metabolic activity of intestinal bacterial flora.

24Colon diverticulitis after kidney transplantation

L. Szabó, R. Fedor, Zs. Kincses, L. AsztalosUniversity of Debrecen, 1st Department of Surgery, Hungary

Introduction: Diverticular disease has been reported in up to 42% of patients with endstage renal disease. Complicated diverticulitis defined as diverticulitis involving freeperforation, abscess, phlegmon or fistula after renal transplantation was reported as1.1% in a recent study.

Methods: 530 kidney transplantations were performed at 1st Department of Surgery,University of Debrecen, Debrecen, Hungary from 1991 to 2005. Diverticulitis occurredin two patients.

Results: The first patient was transplanted in March 2000. Urine excretion startedimmediately after transplantation, serum creatinine was decreasing. Next day the patienthad a lower abdominal pain. His complaints referred to diverticulitis which was verifiedby colonoscopy. He had fever, a palpable abdominal mass, ultrasonography showedinterintestinal abscess, so he was operated on. The sigmoid bowel was resected,Hartmann procedure was performed. The bowel continuity was re-established inNovember 2000. The patient is well with a good renal function.The second patient was transplanted in December 2000. He was admitted with acuteabdomen in September 2003. He was operated on and perforated sigmoid diverticulitiswas found, Hartmann procedure was performed. Reconstruction was done in July 2004.This patient also recovered and has a good renal function.

Discussion/Conclusion: There are numerous risk factors in the pathogenesis of colondiverticulitis in renal transplant patients: uremia, disorders of lipid metabolism, polycystickidney disease, cytomegalovirus infection, immunosuppressive drugs. All possible riskfactors have to be taken in consideration during the follow up of these patients.Choosing the optimal regimen, occurrence of diverticulitis can be lowered; earlydiagnosis can improve the survival.

25Changing indication for surgery in cases of uncomplicateddiverticular disease

Rezsö Szlávik, O. Miskolci, J. Weltner, P. Kupcsulik1st Department Surgery, Semmelweis University, School of Medicine, Hungary

Introduction: The traditional indication for surgery of diverticular disease is any of thecomplications thereof. On the other hand, acute interventions for perforating diverticulitiswith or without diffuse peritonitis or perisigmoid abscess are of high risk.

Methods: Patient histories of 168 consecutive patients with the diagnosis of diverticulardisease were reviewed. 71 of them underwent surgical intervention, typically Hartman'sprocedure. A second intervention, namely reconstruction of the gut was performed 2-3month later, also involving some risk.

Results: 42.3 percent of our patients were operated for acute or chronic complicationsof the disease. The other 97 patients were successfully treated with antibiotics and otherdrugs. There was one death in this second group. There was no death followingreconstruction of the gut, but we had one thrombo-embolism and one severe heartfailure as complication. Complicated wound healing happened eight times (11%)

perforation bleeding abscess fistula obstruction total mortality

11 38 14 5 3 71 4

6.5% 22.6% 8.3% 3.0% 1.8% 42.3% 2.4%

Discussion/Conclusion: Septic complications of diverticular disease are frequent.Surgical interventions during the acute phase of the disease are of high risk, especiallyif we add the risk of a second operation resulting the reconstruction of the gut or closinga protective stoma. Prophylactic resection of segmental diverticular disease seems tobe justified.

26Diverticulosis coexisting with other pathologic changes in colon

Szura Miroslaw, Matyja Andrzej, Solecki Rafal, Blaut Urszula, Kekus JerzySCDZ Medicina, Krakow, Poland

Introduction: A basic diagnostic method used to differentiate colonic pathologies iscolonoscopy. Colonic diverticulosis occur mostly in the patients over 50 years. Thoughpresenting symptoms, such as edema, constipation, left hypogastric pain are suggestiveof colonic diverticulosis, they may also represent other clinical conditions.Retrospective analysis of the incidence of colonic diverticulosis coexisting with otherpathologies in colon based on colonoscopy findings.

Methods: Between 2000 - 2004, 9289 colonoscopies were performed. Theexaminations were performed on ambulatory basis or during one-day hospitalization.Patients' data as well as examination images were archivized to be subsequently usedin the retrospective analysis.

Results: A group consisted of 5436 women and 3853 men at the mean age of 54,9years (age range 17-91 ± 11,4 years). Colonoscopy detected colonic diverticulosis in1985 patients, polyps in 2456 (26.4%), cancer in 259 (2.8%), colitis in 606 (6.5%),hemorrhoidal varices in 3921 (44.2%), and angiomas in 110 (1.2%) patients. Colonicdiverticulosis coexisted in 648 (44.2%) cases with polyps (26.4%), in 40 (15.4%) withcancer, in 68 (11.2%) with colitis, in 831(21.2%) with hemorrhoidal varices and in 32(29.1%) with angiomas.

Discussion/Conclusion: Colonic diverticulosis coexist with other colon pathologies inover 50% of cases. In about 25% of patients colon polyps gave symptoms similar tocolonic diverticulosis. The observations confirm the usefulness of colonoscopy as thebasic diagnostic tool differentiating colon pathologies.

27Occult lower gastrointestinal bleeding in diverticular disease

G. Vosskamp, S. Schanz, G. Müller, W. KruisDepartment of Inner Medicine, Evangelisches Krankenhaus Kalk, Buchforststr. 2, 51103Cologne, Germany

Colonic diverticula are considered to cause 40% of all lower gastrointestinal tractbleeding episodes; 3-5% of them are severe and life-threatening.Yet it has to be emphasized that colonic diverticula and other mucosal lesions, whichcould possibly bleed, coincide in about 42% and that diverticula are mistaken for thesource of gastrointestinal tract bleeding in nearly 9%.

Introduction: A 78-year-old-woman with a history of painless meleana over the periodof several weeks was admitted to hospital in need of transfusion.

Methods: An esophagogastroduodenoscopy was performed and showed normalmucosal tissue. Colonoscopy detected diverticula in the left colon apart from fresh bloodin the whole colon. The source of bleeding could not be exactly identified. ATechnetium-99m-labeled red cell scan was performed as the patient presented with thesecond bleeding episode. This procedure located the source of bleeding in the rightcolon as well as a second colonoscopy, which now detected an active capillary bleedingin the coecum without any mucosal lesion.

Results: The patient was applied to the surgeon for right hemicolectomy. After theoperation a piece of chickenbone, which had led to the chronic bleeding, was found inthe wall of the coecum. After surgery was performed, the patient recovered fast withoutany complications or re-bleeding episodes.

Discussion/Conclusion: This case presents the coincidence of colonic diverticula anda foreign body which penetrated into the colonic wall in a patient with gastrointestinaltract bleeding. Only after enlarged diagnostical investigations the source of bleedingcould be identified and cured surgically. The importance of this fact has been elaboratedby a number of studies which emphasize that the rate of complications and re-bleedingis much higher in colonic resections without the previous location of the bleeding site.

28Mercury - a candidate neurotoxin in the pathogenesis ofdiverticular disease

List and order of authorsMr Mark Golder, FRCS1, Dr Lucy Ghali, PhD2, Ben Martins, BSc3, Dr Monika Hansson,PhD4, Dr David E Burleigh, PhD5, Mr Peter J Lunniss, MS, FRCS1, Professor MalcolmLaw, FRCP6, Professor Harshad A Navsaria PhD2, David Gazzard C Chem, MRSC3, DrManuchehr Abedi-Valugerdi, PhD4, 7, Professor Norman S Williams, MS, FRCS1

1Centre for Academic Surgery, 2Centre for Cutaneous Research, 5Department of Adultand Paediatric Gastroenterology and 6Department of Environmental and PreventativeMedicine, Barts and The London School of Medicine and Dentistry, Whitechapel,London E1 1BB, UK, 3The National Laboratory Service, Environmental Agency, Wales,UK, 4Department of Immunology, the Wenner-Gren Institute, Arrhenius Laboratories forthe Natural Sciences, Stockholm University, Sweden,7The Department of Medicine,Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden

Source of fundingThe Sir Alan Parks Research fund provided the financial support for this project.

Conflict of interest statementThere were no conflicts of interest.

AcknowledgementsWe thank Professor S Dorudi for providing us with many of the bowel specimens, Dr KEto, Director of Clinical Medicine, Institute for Minamata Disease, Japan, for providingus with copies of that Institute's reports on mercury toxicity in Japan and Simon Chaplin,Senior Curator of The Royal College of Surgeons of England, for his advice regardingthe museum's historical specimens.

Key wordsMercury. Toxicity. Environment. Diverticular Disease. Colon. Smooth muscle.Muscarinic M3 receptors. Acetylcholine. Denervation hypersensitivity. Human. Murine.

Abstract

Background: Recent evidence challenges the "low-fibre" hypothesis of diverticulardisease [DD] and suggests that it may be caused by exposure to an as yet unidentifiedenvironmental agent. Disruption in colonic cholinergic activity, including up-regulationof smooth muscle M3-receptors, appears pivotal in DD, but its cause remains unknown.Mercury, an environmental neurotoxin, exhibits anti-cholinergic activity, bioaccumulatesin tissues and has a latent mode of action.

Methods: Human sigmoid colon specimens (10 DD, 10 controls), from anteriorresections, were analysed for mercury concentration using Inductively-Coupled-Plasma-Mass-Spectrometry. 10 mice [5 x SJL (mercury-immune-sensitive) and 5 x DBA/2(mercury-immune-resistant)] drank water, containing mercury (3.7 mg/litre Hg2+) for 12

weeks. 10 controls consumed uncontaminated water. Murine distal colon specimenswere then analysed for mercury, plus colonic M3-receptor density, using immunohisto-chemistry.

Results: Potentially neurotoxic levels of mercury were present in all diverticular andmany control specimens. Median concentration in DD mucosa was 17 :g/Kg range(7-980) controls 13 (0-71) p = 0A14], circular muscle 20 (3-100) controls 5 (0-36) p =0.06]. In exposed-mice, mercury was present in the colon wall, median concentration2.2 [x 103] :g/Kg range (0.4,3.2) and there was up-regulation smooth muscleM3-receptors: circular muscle median % surface area M3-receptors 9.1 range (4.4,15.7)controls 3.4 (1.1,14.0) p = 0.015 and longitudinal muscle 11.9 (7.0,20.1) controls 5.6(2.5,16.8) p = 0.005.

Conclusions: Finding potentially neurotoxic levels of mercury in the colon wall inhumans, and up-regulation of colonic M3-receptors in mice exposed to mercury raisesthe possibility that mercury bioaccumulation and toxicity contributes to the pathogenesisof human diverticular disease.

29Diverticulitis of the sigmoid colon: Trends in surgical manage-ment in a German university hospital

C. Ketscher, T. Strauss, P. Hornung, K. W. Jauch, M. E. KreisLudwig-Maximilians-University Munich, Department of Surgery, Munich, Germany

Introduction: The surgical approach to acute and recurrent diverticulitis has changedin recent years. In acute diverticulitis, emergency sigmoid colectomy and primaryanastomosis has been advocated for perforation even in the presence of peritonitis.Elective sigmoid colectomy for recurrent disease is increasingly performed by thelaparoscopic-assisted technique. We aimed to study the therapeutic approach over timein a university hospital.

Methods: A retrospective database review was performed for all patients operated fordiverticulitis at the University Hospital Großhadern, Department of Surgery, Munich.Data were evaluated over a three year period from 2002 until 2004. Trends during theobservation period were analysed by Spearman Correlation. P < 0.05 was consideredsignificant.

Results: In the years 2002, 2003 and 2004, 41, 57 and 38 patients were operated atour institution. During the three year period, 71, 81 and 86% of the operated patientsunderwent elective surgery (p < 0.05) and 48, 63 and 33% were operated on bylaparoscopic means (n.s.). In contrast, 29, 19, and 14% of all patients were operatedon an emergency basis. In this acutely operated group, 25, 91 and 0% underwentsigmoid colectomy with primary anastomosis, while 17, 9 and 0% had primaryanastomosis with protective ileostomy. 58, 0, and 100% of the patients underwent aHartmann procedure.

Conclusions: Despite emerging evidence that perforated diverticulitis of the sigmoidcolon may be managed by sigmoid colectomy and primary anastomosis, this approachappears to have varying popularity among academic surgeons. The frequency oflaparoscopic surgery was also variable over time which is possibly related to changesin the team of staff surgeons who may differ in their level of training concerninglaparoscopic techniques.

Author Index to Poster Abstracts(Name - Poster Number)

Abedi-Valugerdi, M. 28Asztalos, L. 24

Bartha, I. 16Bicknell, C. 17Bintintan, V. 7Blachut, K. 1, 2Blaut, U. 3, 11, 26Bodrogi, P. 16Boicean, A.B. 20Bruch, H.-P. 21, 22Burleigh, D.E. 28

Calbureanu Popesu, M. 18Coman, A.C. 20

Deac, M. 20

Ejma-Multanski, J. 3, 11Elsing, C. 4Elton, C. 17

Farke, S. 21, 22Fedor, R. 24Fratila, O. 5Fric, P. 6Funariu, G. 7

Gaponov, I. 8, 9Gaponov, V.V. 8, 9Gazzard, D. 28Gerova, V. 10Ghali, L. 28Glatzle, J. 19Gniady, J. 3, 11Golder, M. 28Goldis, A. 12Goldis, R. 12Gross-Weege, W. 4

Hansson, M. 28Harrison, R. 17Herzog, T. 13Hildebrand, P. 21Hornung, P. 29

Ianosi, G. 18

Jauch, K.W. 29

Kadyan, H. 10Karagiannis, J.A. 14Kasparek, M.S. 15, 19Kekus, J. 26Kempinski, R. 1Ketscher, C. 29Kincses, Z. 16, 24Königsrainer, A. 15Kreis, M. 15, 19, 29Kruis, W. 27Kupcsulik, P. 25

Law, M. 28Lazar, D. 12Lenghel, A. 5Lind, J.S.W. 17Lungu, V. 12Lunniss, P.J. 28

Maghiar, A. 5Marecik, J. 3, 11Martins, B. 28Mathou, N. 14Mathur, P. 17Matyja, A. 26Mercut, D. 18Miskolci, O. 25Mitchell, I. 17Mittelkötter, U. 13Müller, C. 13Müller, G. 27Müller, M.H. 19

Navsaria, H.A. 28Neagoe, D. 18

Owen, D. 17

Paradowski, L. 2Paraskeva, K.D. 14Petrascu, O. 20

Petrou, M. 17Piriova, E.P. 10Poniewierka, E. 1

Racanel, F. 18

Salamon, A. 23Schanz, S. 27Schiele, E. 15Schwandner, O. 21, 22Seicean, R. 7Seitz, G. 15Shevtsova, Z.I. 8, 9Simon, L. 23Solecki, R. 26Stoinov, S. 10Strauss, T. 29Szabó, L. 24Szlávik, R. 25Szura, M. 26

Toma, V. 18Tomns, N. 17

Uhl, W.H.

Vernic, C. 12Vosskamp, G. 27

Weltner, J. 25Weyhe, D. 13Williams, N.S. 28

Zavoral, M. 6Zivec, M. 4