Managing Diverticulosis and Diverticular Disease
A currently active topic of debate is that of the ways in which to treat acute diverticulitis. Controlled trials show that antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. Thus, antibiotics should be reserved for the treatment of uncomplicated diverticulitis with comorbidities and complicated diverticulitis. The reason why antibiotic treatment does not appear to work remains unknown, but given study results to date, the use of antibiotics in treating both SUDD and acute diverticulitis is becoming questionable. Many specific points should be considered regarding the treatment of acute diverticulitis patients with antibiotics, ranging from the selection of an antibiotic based on minimum effective concentrations and bacterial sensitivity, to assessment of pharmacokinetics and pharmacogenomics of antibiotics in this specific population. Future clinical trials investigating antibiotic therapy in acute diverticulitis patients need to provide additional strategies to achieve individualisation.
Another point currently under debate is how to prevent diverticulitis recurrence. Although promising in open-label trials, both rifaximin and mesalazine were found to be ineffective in secondary prevention of diverticulitis in RCT. The reasons for this lack of effect remain to be elucidated, with the lack of effect surprising, particularly considering that both drugs are effective in placebo-controlled studies in controlling symptom of SUDD, and that mesalazine is also effective in primary prevention of acute diverticulitis. Heterogeneity in the population enrolled, heterogeneity in the type of mesalazine investigated linked to the mechanism of discharging through the colon, and heterogeneity in endpoints assessed, may be detected in all trials published, with all of these factors able to influence results.
Improvement in selecting patients according to the colonic characteristics may be an option to increase therapeutic efficacy. To this end, an endoscopic classification of DD has recently been developed and validated. This classification, called DICA (Diverticular Inflammation and Complications Assessment), assesses four main items (diverticulosis extension, number of diverticula in each district, presence of inflammation, presence of complications) and some sub-items (Figure 7), and scores the disease as three grades: DICA 1, DICA 2 and DICA 3 (see Table 7). Preliminary retrospective data found this classification able to predict the outcome of the disease according to the severity of the score. In other words, simple and/or asymptomatic diverticulosis does not appear to need any maintenance treatment to prevent occurrence of complications, while a colon with signs of recurrent inflammatory attack may be unresponsive to maintenance treatment to prevent recurrence of complications. On the contrary, DICA 2 seems to be very responsive to scheduled treatment. In other words, symptomatic diverticulosis with/without signs of inflammation responds very well to maintenance treatment for the prevention of occurrence/recurrence of complications. If further, prospective studies confirm these results, then we will have a clear subgroup of patients that can be expected to benefit from scheduled maintaining treatment.
(Enlarge Image)
Figure 7.
DICA Classification. This classification scores diverticular disease according to the endoscopic finding of the colon harbouring diverticula. Each of those findings gives a specific scoring (see Table 6 for scoring).
In conclusion, DD is a multifactorial disease in which optimal patients' stratification according to the severity of the disease may guarantee therapeutic success. Recent radiological and endoscopic classifications could be the optimal tool to reach this target. Furthermore, prospective studies adopting these classification are therefore urgently required, to have a tailored therapeutic strategy.
Future Trends in Managing DD
A currently active topic of debate is that of the ways in which to treat acute diverticulitis. Controlled trials show that antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. Thus, antibiotics should be reserved for the treatment of uncomplicated diverticulitis with comorbidities and complicated diverticulitis. The reason why antibiotic treatment does not appear to work remains unknown, but given study results to date, the use of antibiotics in treating both SUDD and acute diverticulitis is becoming questionable. Many specific points should be considered regarding the treatment of acute diverticulitis patients with antibiotics, ranging from the selection of an antibiotic based on minimum effective concentrations and bacterial sensitivity, to assessment of pharmacokinetics and pharmacogenomics of antibiotics in this specific population. Future clinical trials investigating antibiotic therapy in acute diverticulitis patients need to provide additional strategies to achieve individualisation.
Another point currently under debate is how to prevent diverticulitis recurrence. Although promising in open-label trials, both rifaximin and mesalazine were found to be ineffective in secondary prevention of diverticulitis in RCT. The reasons for this lack of effect remain to be elucidated, with the lack of effect surprising, particularly considering that both drugs are effective in placebo-controlled studies in controlling symptom of SUDD, and that mesalazine is also effective in primary prevention of acute diverticulitis. Heterogeneity in the population enrolled, heterogeneity in the type of mesalazine investigated linked to the mechanism of discharging through the colon, and heterogeneity in endpoints assessed, may be detected in all trials published, with all of these factors able to influence results.
Improvement in selecting patients according to the colonic characteristics may be an option to increase therapeutic efficacy. To this end, an endoscopic classification of DD has recently been developed and validated. This classification, called DICA (Diverticular Inflammation and Complications Assessment), assesses four main items (diverticulosis extension, number of diverticula in each district, presence of inflammation, presence of complications) and some sub-items (Figure 7), and scores the disease as three grades: DICA 1, DICA 2 and DICA 3 (see Table 7). Preliminary retrospective data found this classification able to predict the outcome of the disease according to the severity of the score. In other words, simple and/or asymptomatic diverticulosis does not appear to need any maintenance treatment to prevent occurrence of complications, while a colon with signs of recurrent inflammatory attack may be unresponsive to maintenance treatment to prevent recurrence of complications. On the contrary, DICA 2 seems to be very responsive to scheduled treatment. In other words, symptomatic diverticulosis with/without signs of inflammation responds very well to maintenance treatment for the prevention of occurrence/recurrence of complications. If further, prospective studies confirm these results, then we will have a clear subgroup of patients that can be expected to benefit from scheduled maintaining treatment.
(Enlarge Image)
Figure 7.
DICA Classification. This classification scores diverticular disease according to the endoscopic finding of the colon harbouring diverticula. Each of those findings gives a specific scoring (see Table 6 for scoring).
In conclusion, DD is a multifactorial disease in which optimal patients' stratification according to the severity of the disease may guarantee therapeutic success. Recent radiological and endoscopic classifications could be the optimal tool to reach this target. Furthermore, prospective studies adopting these classification are therefore urgently required, to have a tailored therapeutic strategy.
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