objectives - american college of...
TRANSCRIPT
Byron P. Vaughn, MD
Spectrum of Diverticular Disorders:SUDD, SCAD
Byron P. Vaughn, MDAssistant Professor of Medicine
Division of Gastroenterology, Hepatology and Nutrition
University of Minnesota
Objectives
• View diverticular disease as a spectrum of inflammatory diseases
• Focus on pathophysiology and treatment of: I. Symptomatic uncomplicated diverticular disease
(SUDD)II. Segmental colitis associated with diverticula
(SCAD)
2016 ACG Midwest Regional Postgraduate Course Copyright 2016 American College of Gastroenterology
Page 1 of 10
Byron P. Vaughn, MD
Diverticula
Vasa recta Diverticulum
False (pseudo) diverticula herniation of mucosa and submucosa through lamina propria
Mimura T. Pathophysiology of diverticular disease. Best Pracice & Research Clinical Gastroenterol. 2002;16:563-76
Spectrum of diverticular disease
Diverticulosis
Diverticular disease
Diverticulitis
Acute diverticulitis
Chronic diverticulitis
Chronic recurrent
diverticulitisSCAD
SUDD
Asymptomatic diverticulosis
Strate LL, et al. Am J Gastroenterol. 2012;107:1486-93
2016 ACG Midwest Regional Postgraduate Course Copyright 2016 American College of Gastroenterology
Page 2 of 10
Byron P. Vaughn, MD
Diverticular disease
Low grade inflammation
Alterations in gut microbiota
Visceral hypersensitivity
Abnormal colon motility
Strate LL, et al. Am J Gastroenterol. 2012;107:1486-93
Increased colonic pressure
Constipation
Diverticular obstruction
Low fiber diet
Symptomatic Uncomplicated Diverticular Disease (SUDD)
• Estimated 20% prevalence in subjects with diverticulosis• Sometimes called: smoldering diverticulitis• Definition not consistent in literature
– Abdominal pain AND change in bowel habits2
– Abdominal pain OR change in bowel habits3
• Clinical criteria for SUDD separate from IBS4
– Prolonged less frequent abdominal pain (>24 hours)– No relief with defecation
1Elisei W, et al. Ann Gastroenterol. 2016;29:24-322Kohler L, et al. Surg Endosc. 1999;13:430-63Strate LL, et al. Am J Gastroenterol. 2012;107:1486-934Annibale B, et al. Int J Colorectal Dis. 2012;27:1151-59
Persistent abdominal pain attributed to diverticula in the absence of macroscopic inflammation (colitis or diverticulitis)1
2016 ACG Midwest Regional Postgraduate Course Copyright 2016 American College of Gastroenterology
Page 3 of 10
Byron P. Vaughn, MD
SUDD as spectrum of inflammatory disease
Acute diverticulitis SUDDMacroscopic
inflammation Microscopic inflammation
10-25% of subjects with SUDD may develop acute diverticulitis
Inflammation in SUDD
• Mayo surgical records: sigmoid resection for diverticular disease (1988 – 1997)
• 5% (n=47) done for smoldering DD (aka SUDD)
Acute and chronic mucosal inflammation
Complete resolution of presenting symptom
and pain free
Horgan AF et al. Dis Colon Rectum 2001;44:1315-8
No correlation
2016 ACG Midwest Regional Postgraduate Course Copyright 2016 American College of Gastroenterology
Page 4 of 10
Byron P. Vaughn, MD
TNF elevated in SUDD
AUD SUDD AD SCAD UC HC
AUD: Acute uncomplicated diverticulitisAD: Asymptomatic diverticulosisHC: Healthy controlTursi A, et al. Colorectal Dis. 2012;14:e258-63
Visceral hypersensitivity / IBS overlap
Clemens CHM, et al. Gut 2004;54:717-722
Isobaric distention of the sigmoid and rectum
2016 ACG Midwest Regional Postgraduate Course Copyright 2016 American College of Gastroenterology
Page 5 of 10
Byron P. Vaughn, MD
SUDD and colonic microbiota
• Bacterial overgrowth in setting of fecal stasis• Low fiber diet putative risk factor for SUDD
– Low fiber associated with lower levels of Bifidobacteria and Faecalibacterium prausnitzii
• Toll-like receptor abnormalities in mucosa of subjects with SUDD versus healthy controls– Reverses or improves with rifaximin
Cianci R, et al. J Immunol Res. 2014:696812Hooda S, et al. J Nutr. 2012; 142:1259-65
SUDD Treatment
• Fiber– Conflicting results from small trials– Pressure?– Microbiome?
• Mesalamine – 3 RCTs– Varying dosing of mesalamine– General trend of improving symptoms with
daily therapy (1.6g/day)• Antibiotics
– Rifaximin + fiber: 29% reduction in symptoms versus fiber alone
• Smooth muscle relaxer ? • Probiotics ?
– Lack of comparative studies– Pre/post analysis favors probiotics plus
fiber
Brodribb AJ. Lancet. 1977;26:664-6Gatta L, et al. J Clin Gastroenterol. 2010;44:113-9Bianchi M, et al. Aliment Pharmacol Ther. 2011;33:902-10
Rifaximin: risk reduction
Scaioli E, et al. Dig Dis Sci. 2016;61:673-683
2016 ACG Midwest Regional Postgraduate Course Copyright 2016 American College of Gastroenterology
Page 6 of 10
Byron P. Vaughn, MD
Segmental colitis associated with diverticula (SCAD)
• Early 1980 – reports of endoscopically active inflammation in the sigmoid in areas of diverticula
• Classic presentation: age >60 (M > F), subacute hematochezia, altered bowel function and abdominal pain
• Endoscopy: patchy mucosal hemorrhage granularity and exudate without gross ulceration
• Biopsies: Focal chronic active colitis withoutgranulomas
• Prevalence in pts with diverticulosis: 0.26 – 1.5%Cawthorn SJ, et al. Gut 1983;25:500Peppercorn Ma, J Clin Gastroenterol. 2004;38:S8-10
Mann NS, Hoda KK. Hepatogastroenterology. 2012;59:2119-21Tursi A, et al. Colorectal Dis. 2010:12:464-70
Pathology of SCAD
SCAD• Cryptitis• Crypt abscesses • Mononuclear infiltrate in LP• Basal lymphoid aggregates • Chronicity:
– Basal lymphoplasmacytosis– Crypt distortion – Paneth cell metaplasia
Not in SCAD• Granulomas
– Except in setting of crypt rupture
• Inflammation beyond mucosa (generally)
• Rectal involvement• Overt changes of
diverticulitis
Lamps LW and Knapple WL. Clin gastroenterol Hepatol 2007; 5:27
Ulcerative colitisCrohn’s colitis
Infectious colitisNSAID colitis
Ischemic colitis
2016 ACG Midwest Regional Postgraduate Course Copyright 2016 American College of Gastroenterology
Page 7 of 10
Byron P. Vaughn, MD
SCAD: pathophysiology
Lamps LW and Knapple WL. Clin gastroenterol Hepatol 2007; 5:27Strate LL, et al. Am J Gastroenterol. 2012;107:1486-93
Ludeman L, Shepard NA. Pathology. 2002;34:568Mulhall AM, et al. Dis Colon Rectum. 2009; 52:1072Iedardi E, et al. Dig Dis Sci. 2008;53:1865-8
Mucosal prolapse
Fecal stasis
Local ischemia
Subserolsal peridiverticulosis
Dysbiosis
Immunologic•Tissue TNF elevated
in SCAD
10% will progress to IBD
Endoscopic patterns of SCAD
Crescentic fold
Mild to moderate UC - like
Crohn’s colitis - like Severe UC-
like
Tursi A, et al. Colorectal Dis. 2010:12:464-70
A B
C D
2016 ACG Midwest Regional Postgraduate Course Copyright 2016 American College of Gastroenterology
Page 8 of 10
Byron P. Vaughn, MD
SCAD treatment
• Retrospective case series/cohorts– Observation alone– 5-ASA (UC dosing):
• 80% symptom resolution within 6 months
– Antibiotics: Ciprofloxacin or metronidazole
– Prednisone/steroids – Surgical resection:
refractory symptoms. bleeding/anemia, obstruction
• Prospective– Beclomethasone
Dipropionate + VSL #3• 12 subjects, open label, no
control group
Freeman HJ. Dig Dis Sci. 2008;53:2452-7Makapugay LM and Dean PJ. Am J Surg Pathol. 1996;20:94-102Tursi A, et al. J Clin Gastroenterol. 2005;39:644-5
Generally a mild, self limited course
SCAD treatment – Systematic review
227 subjects71%SCAD
142 medically 28 surgically
~25%recurred
after “treatment”
Mulhall AM, et al. Dis Colon Rectum. 2009;52:1072-9
18 studies(1974-2008)
Remainder IBD and diverticulitis
2016 ACG Midwest Regional Postgraduate Course Copyright 2016 American College of Gastroenterology
Page 9 of 10
Byron P. Vaughn, MD
Take home points:• Paradigm of diverticular disease is changing
– Spectrum of chronic inflammation• SUDD
– Appears distinct from IBS– Inflammatory component– Evidence for mesalamine and antibiotics
• SCAD– Generally mild course– Observation, mesalamine and antibiotics– ~10% progression to overt IBD– Steroids and surgery may be needed
Thank you
2016 ACG Midwest Regional Postgraduate Course Copyright 2016 American College of Gastroenterology
Page 10 of 10