Postinfectious Irritable Bowel Syndrome

Summary Colonic diverticulosis refers to small outpouchings from the colonic lumen due to mucosal herniation through the colonic wall at sites of vascular perforation. Abnormal colonic motility and inadequate intake of dietary fibre have been implicated in its pathogenesis. This acquired abnormality is typically found in developed countries, and its prevalence rises with age. Most patients affected will remain entirely asymptomatic; however, 10–20% of those affected can manifest clinical syndromes, mainly diverticulitis and diverticular haemorrhage. As our elderly population grows, we can anticipate a concomitant rise in the number of patients with diverticular disease. Here, we review the incidence, pathophysiology, clinical presentation, and management of diverticular disease of the colon and its complications.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(04)15597-9.pdf

Diverticular Disease of the Colon

It is increasingly perceived that gut host–microbial interactions are important elements in the pathogenesis of functional gastrointestinal disorders (FGID) The most convincing evidence to date is the finding that functional dyspepsia and irritable bowel syndrome (IBS) may develop in predisposed individuals following a bout of infectious gastroenteritis There has been a great deal of interest in the potential clinical and therapeutic implications of small intestinal bacterial overgrowth in IBS However, this theory has generated much debate because the evidence is largely based on breath tests which have not been validated The introduction of culture-independent molecular techniques provides a major advancement in our understanding of the microbial community in FGID Results from 16S rRNA-based microbiota profiling approaches demonstrate both quantitative and qualitative changes of mucosal and faecal gut microbiota, particularly in IBS Investigators are also starting to measure host–microbial interactions in IBS The current working hypothesis is that abnormal microbiota activate mucosal innate immune responses which increase epithelial permeability, activate nociceptive sensory pathways and dysregulate the enteric nervous system While we await important insights in this field, the microbiota is already a therapeutic target Existing controlled trials of dietary manipulation, prebiotics, probiotics, synbiotics and non-absorbable antibiotics are promising, although most are limited by suboptimal design and small sample size In this article, the authors provide a critical review of current hypotheses regarding the pathogenetic involvement of microbiota in FGID and evaluate the results of microbiota-directed interventions The authors also provide clinical guidance on modulation of gut microbiota in IBS

https://gut.bmj.com/content/gutjnl/62/1/159.full.pdf

Intestinal microbiota in functional bowel disorders: a Rome foundation report

A 28-year-old woman presents with a 7-month history of recurrent, crampy pain in the left lower abdominal quadrant, bloating with abdominal distention, and frequent, loose stools. She reports having had similar but milder symptoms since childhood. She spends long times in the bathroom because she is worried about uncontrollable discomfort and fecal soiling if she does not completely empty her bowels before leaving the house. She feels anxious and fatigued and is frustrated that her previous physician did not seem to take her distress seriously. Physical examination is unremarkable except for tenderness over the left lower quadrant. How should her case be evaluated and treated?

/pdf/irritable-bowel-syndrome-4cbjzv3crp.pdf

Irritable bowel syndrome

Background: The incidence of acute left-sided colonic diverticulitis (ACD) is increasing in the Western world. To improve the quality of patient care, a guideline

/pdf/guidelines-of-diagnostics-and-treatment-of-acute-left-sided-1po8mr4e3z.pdf

Guidelines of Diagnostics and Treatment of Acute Left-Sided Colonic Diverticulitis

BackgroundWhile the association of recurrent bouts of abdominal pain with colonic diverticulosis is well recognized, the cause of this pain is obscure since in most cases it occurs without obvious diverticulitis or other potential causes.AimsTo define the patterns of pain in diverticular disease and

Patterns of pain in diverticular disease and the influence of acute diverticulitis.

A population-based study of perforated diverticular disease incidence and associated mortality

Background:

A significant number of patients with colonic diverticula experience unexplained, recurrent, short-lived but often debilitating abdominal pain and alteration in bowel habit. Such patients account for many medical consultations every year but, as our understanding of the cause of their symptoms remains imperfect, treatment options are limited. This article reviews the possible mechanisms that may be responsible for the symptoms of diverticular disease.



Methods:

Medline and Science Citation Index searches were performed to locate English language articles relating to colonic diverticula and symptoms published between January 1966 and July 2002. Manual cross-referencing was also performed and some historical articles were included.



Results and conclusion:

Several theories now exist about the mechanisms underlying the symptoms of diverticular disease. Initial studies suggested that they may be due to alterations in the intracolonic pressure, extrapolating earlier thoughts on the likely pathogenesis of diverticula. It seems more likely, however, that several inter-related processes, such as muscular dysfunction, visceral hypersensitivity and inflammation, are involved in symptom generation. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Origin of symptoms in diverticular disease

Background & Aims: Perforated diverticular disease represents the most serious complication of diverticular disease, but little is known regarding its occurrence and mortality. We aimed to determine the incidence and mortality associated with diverticular perforation and the influence of comorbidity. Methods: We used a population-based cohort study using patients with perforated diverticular disease and population controls identified from 1990 to 2005 in the General Practice Research Database (GPRD). Incidence and mortality rates were modelled using Poisson and Cox regression. Comorbidity was quantified using the Charlson index. Results: We identified 953 incident patients. The overall incidence was 2.66 (95% confidence interval [CI]: 2.49‐2.83) per 100,000 person-years. The incidence rates increased 2.28-fold (95% CI: 1.79‐2.95) when corrected for age and sex between 1990 and 2005. The risk of death was highest in the first year with a 6-fold increase (hazard ratio [HR], 5.63; 95% CI: 4.68‐6.77). Adjusted for age and sex, the risk of death in the first year was highest in those with lowest comorbidity (HR, 11.11; 95% CI: 8.06‐15.31), but the absolute mortality rates were greatest in those with the highest comorbidity (263.1 per 1000 person-years). Conclusions: The incidence of perforated diverticular disease has doubled over the period of the study. Patients presenting with a perforated diverticulum are 6 times more likely to die than the general population during the first year following perforation. Those who have the greatest comorbidity are the most likely to die; however, those with least comorbidity have an 11-fold increase in mortality in the first year.

CLINICAL—ALIMENTARY TRACT A Population-Based Study of Perforated Diverticular Disease Incidence and Associated Mortality

Background:
The importance of psychological factors in symptom expression in diverticulosis is unknown. This follow-up study assessed the relative importance of colonic and psychological factors in symptom expression.

Methods:
Patients with barium enema-proven diverticula were sent a bowel symptom questionnaire in 1999 and again in 2006 with additional psychological questionnaires included.

Results:
Some 170 of 261 initial responders were eligible for follow-up and 124 (72·9 per cent) provided complete replies. Forty-two (33·9 per cent) of 124 respondents experienced recurrent abdominal pain a median of 3·5 (interquartile range (i.q.r.) 2·00–9·25) days per month, with a median duration of 1 (i.q.r. 0·7–2) h. Multivariable analysis identified a history of acute diverticulitis (odds ratio 3·98; P = 0·010) and a raised score on the Hospital Anxiety and Depression Scale (odds ratio 2·53; P = 0·030) as the best predictors of recurrent pain.

Conclusion:
Psychological and colonic factors are important in symptom expression in diverticulosis. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Psychological and colonic factors in painful diverticulosis

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