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Diverticular disease in adolescence
Best Practice & Research Clinical Gastroenterology Vol. 16, No. 4, pp. 621±634, 2002
doi:10.1053/bega.2002.0303, available online at http://www.idealibrary.com on
7 Diverticular disease in adolescence Nadeem Ahmad Afzal
MRCPCH, MRCP
Research Fellow and Honorary Specialist Registrar in Paediatric Gastroenterology
Mike Thomson
FRCPCH, MD
Clinical Director and Consultant in Paediatric Gastroenterology Centre for Paediatric Gastroenterology, Royal Free Hospital, Pond Street, Hampstead, London, NW3 2QG, UK
Diverticular disease is rare in the adolescent. Acute diverticulitis is almost never considered as a diagnosis for a young patient presenting with abdominal pain. Unfortunately, unrecognized it may be associated with signi®cant morbidity and mortality. Also, when present, diverticulitis in the young adult is considered to be more aggressive compared to diverticulitis in older adults. Therefore, it is important to recognize, diagnose and manage diverticular disease appropriately in this age group. In tis chapter we will review the available literature on diverticula disease in the adolescent and youn adult, discuss epidemilogy, aetiology and pathogenesis and suggest guidelines for diagnosis and management. Key words: diverticular disease; diverticulitis; diverticulosis; colon; large bowel; young adult; adolescent.
Diverticula, when present, may exist in the small or large intestine. However, the term `diverticular disease' is commonly used for pathology in the large intestine only. Diverticular disease of the large bowel is a very broad term, encompassing diverticulosis, diverticulitis and complicated diverticulitis. The term diverticular disease is also used interchangeably with diverticulitis, which is incorrect. Diverticulosis signi®es the presence of diverticula without any in¯ammation. Non-speci®c bowel symptoms may be present, which overlap considerably with those of irritable bowel syndrome.1 Conversely, diverticulitis is de®ned as the presence of in¯ammation or infection associated with diverticula.2 It is an acute abdominal condition necessitating prompt treatment and emergency surgery in some cases. When associated with obstruction, stricture, ®stula or abscess it is known as complicated diverticulitis.2 Diverticular disease of the small intestine, excepting Meckel's diverticulum, is not uncommon. However, diverticula when present in the small intestine are most frequently present in the duodenum. Small bowel diverticula, except for Meckel's, require no intervention if no signi®cant symptoms are found.3 In this chapter we will address diverticular disease in the large bowel in the adolescent and the young adult (540 years). All correspondence to M. Thomson. Tel: 00 44 207 830 2779; Fax: 00 44 207 830 2146, E-mail: m.thomson @rfc. ucl.ac.uk c 2002 Published by Elsevier Science Ltd. 1521±6918/02/$ - see front matter *
622 N. A. Afzal and M. Thomson
INCIDENCE AND PREVALENCE Diverticulosis occurs in one-third of the population over the age of 45 and in up to twothirds of the population over 85 years of age.4 Of the patients with diverticulosis, 10±25% will progress to diverticulitis.5,6 The true incidence of diverticulosis is not accurately known as it is invariably asymptomatic. In a review of 2000 barium enema studies in patients less than 35 years of age, not one case of diverticulosis was found.4 Lee studied 1014 colons at post-mortem and found evidence of diverticula from the second decade of life, with 6% of the total showing diverticular disease below 40 years of age.7 A post-mortem series of 200 patients by Hughes8 showed diverticular disease in 9% of cases less than 50 years of age but again no diverticula were seen below 30 years of age. Within the total population with diverticular disease, the young (540 years of age) comprise only 2±7%.9±11 However, others have reported an incidence of between 20±29%.12,13 In these studies the incidence was calculated by only using cases of acute diverticulitis as the denominator for calculation, rather than all cases of diverticular disease, possibly accounting for the higher reported incidence. It is also possible that there may be some under-reporting, since not all cases of young people with abdominal pain are investigated speci®cally for diverticular disease.10 Diverticular disease was ®rst reported in a child in 1908 and, subsequently, there have been only rare cases reported in adolescents.14,15 Table 1 summarizes a series of studies published on diverticular disease in those under 40 years of age over the last 26 years. There have been only two reported cases in adolescents.
SEX DISTRIBUTION Diverticular disease is more common in males than females under 40 years of age4,10,12,16±18, although diverticular disease in all age groups is commoner in females.19 This seems to have changed from a male predominance in the earlier part of the 20th century.20 The reasons for this are unknown.
Table 1. Diverticular disease in the young and adolescents; a review of studies in the last 26 years. Reference
Patients 84
Minardi et al (2001) Marinella & Mustafa (2000)69 Spivak et al (1997)67 Vignati et al (1995)68 Ambrosetti et al (1994)42 Konvolinka (1994)35 Acosta et al (1992)13 Schauer et al (1992)34 Freischlag et al (1986)12 Ouriel & Schwartz (1983)10 Chodak et al (1981)18 Simonowitz & Paloyan (1977)16 Eusebio & Eisenberg (1973)9 Ave, average; NR, not recorded.
22 21 63 40 61 29 17 61 17 92 37 33 181
Age 540 540 545 550 550 540 540 540 540 540 540 540 540
(16±40) (mean 34) (27±45) (ave 38) (24±50) (19±39) (23±40) (28±38) (15±40) (21±40) (24±40)
Adolescents 1 None None NR None None None NR None 1 None None None
Diverticular disease in adolescence 623
SOCIO-DEMOGRAPHIC DISTRIBUTION Diverticular disease has been termed a disease of Western civilization. The highest incidences are seen in the UK, the USA, Europe and Australia, but rare in rural Africa and Asia.21,22 However, with the adoption of Western dietary habits (low ®bre) there have been more recent reports from Africa23, Japan24 and Singapore.7 Furthermore, right-sided disease (involvement of the caecum and the ascending colon) is more prevalent in the Asian population7,24±26 compared with left-sided disease (sigmoid and descending colon) in the Western world. Interestingly right-sided disease is also common in those of Japanese descent living in Hawaii.27 AETIOLOGY AND PATHOGENESIS Diverticular disease is common in the elderly and rare in the young. However, certain connective tissue disorders such as Marfan's syndrome28,29 and also the use of steroids6, may predispose to the development of diverticular disease earlier in life. These observations led to an erroneous conclusion that all individuals developing diverticulitis may have a collagen de®ciency in their colons, as seen in Marfan's syndrome patients in whom it was postulated that the colon could be predisposed to mucosal herniation leading to diverticulosis. However, subsequent electron microscopy studies in diverticulosis have shown structurally normal muscle cells in the colon wall, with elastin deposition of twice the normal amount between the muscle cells in the taenia.30 Fibre intake is thought to be an important factor in the evolution of diverticulosis. Fibre ®lls the colon with bulkier, moister faeces, which necessitate less work for the colon. Simply it operates as a low-pressure system, only occasionally evacuating by mass peristalsis into the rectum. Population studies show that diverticular disease subjects consume less ®bre resulting in decreased faecal mass, slower transit with decreased output causing increased pressure generation in the colon in an attempt to propel the faecal mass. Consequently, there is a change in colonic wall compliance, which may occur because of collagen failure. Elastosis may result, causing contraction of the taeniae. This produces the typical contracted structure seen in the excised colonic specimen31, and is perhaps one of the explanations for the changes seen under the electron microscope in diverticulosis. Fibre intake has been found to be inversely proportional to diverticular disease in a prospective follow-up of 51, 259 male health professionals in the USA.32 Over a 6-year period 385 new cases of symptomatic diverticular disease were identi®ed. A signi®cant inverse association was found between insoluble dietary ®bre intake and the risk of subsequently developing symptomatic diverticular disease.33 Schauer et al and Konvolinka have reported obesity to be signi®cantly related to diverticular disease in the young. These patients had so called `diverticulogenic' diets.34,35 Obesity may be the result of increased carbohydrate and decreased ®bre in the diet. Obesity has been associated with diverticular disease in young Hispanic men34 and this problem may also be addressed with a high ®bre diet. The pathogenesis of right-sided diverticular disease is less clear. As in left-sided diverticulitis, thickening of the taenia coli and inner circular muscle is present in rightsided diverticulitis, although to a lesser degree.36 Motility and intra-luminal studies also suggest that high intraluminal pressure and abnormal motility in the ascending colon may be important in the pathogenesis of right-sided diverticula disease.37 All diverticula examined histologically, including cases of single diverticulum, that were previously
624 N. A. Afzal and M. Thomson
believed to be congenital38 were shown to be acquired and caused by herniation of the mucosa through the muscle coat.7,8 Therefore, solitary or multiple diverticulosis on the right or left side of the colon are most likely part of the spectrum of the same disease, with perhaps some in¯uence of genetics and race.7 DIVERTICULOSIS Diverticulosis is asymptomatic but, rarely, may produce symptoms. Therefore, it may only be diagnosed incidentally on barium studies, colonoscopy, or computer tomography (CT) scanning. The presence of diverticula in an asymptomatic patient does not require any further diagnostic evaluation.39 However, it is reasonable to advise a high ®bre diet (see Aetiology and Pathogenesis, above). Patients with diverticulosis may present with lower abdominal pain and with symptoms similar to irritable bowel syndrome. When an adolescent presents with such symptoms the dierential diagnosis is long and warrants a thorough history and examination including determination of growth parameters and pubertal development. In addition, blood tests, which include a full blood count, liver function tests, in¯ammatory markers and coeliac screen, are recommended. Bowel cancer is a main dierential diagnosis in the adult, but is much less likely in an adolescent. There are no randomized controlled trials supporting a role for anti-spasmodics, as advised in the past, and de®nitely no role for antibiotics in the absence of diverticulitis.39 DIVERTICULITIS There are two reasons why it is hard to make a diagnosis of acute diverticulitis in the young. Firstly, diverticulitis is uncommon in the young and rare in the adolescent, hence it is rarely considered in the list of dierential diagnoses of acute abdominal pain. Secondly, the classical features of acute diverticulitis are reported to be present in 535%. Table 2 lists the percentage of reported misdiagnoses. The percentage of misdiagnoses is further increased to more than 90% in right-sided diverticulitis (caecum and ascending colon)40,41 as it may be confused with acute appendicitis (Table 2).
Table 2. Accuracy of diagnosis of acute diverticulitis in the young. Reference
Misdiagnosis (no. of cases) 84
Minardi et al (2001) Marinella & Mustafa (2000)69 Spivak et al (1997)67 Konvolinka (1994)35 Schauer et al (1992)34 Freischlag et al (1986)12 Ouriel & Schwartz (1983)10 Chodak et al (1981)18 Eusebio & Eisenberg (1973)9 Simonowitz & Paloyan (1977)16 Evans & Dawson (1970)85 Kim & Dreiling (1974)86
13 10 28 15 25 8 47 22 56 24 4 3
% 59 48 44 50 41 47 51 63 88 73 44 60
Diverticular disease in adolescence 625
Clinical manifestations of diverticulitis in the young It is reported that 5 35% of young patients present with the known classical features of diverticulitis i.e. fever, leukocytosis, left lower quadrant abdominal pain, mass and tenderness.12,34,35 The commonest presenting features are as follows: 1. Fever (73±90%). 2. Abdominal pain (70±92%), not present on the left side in half of the cases and it may be intermittent or constant. 3. Nausea and vomiting (62%). 4. Diarrhoea (24%). 5. Palpable mass in the abdomen (13±24%). 6. Abdominal tenderness and guarding (80%), although rarely left side alone. 7. Leukocytosis (4 10 106/l).10,12,18,35 Hence the absence of left-sided abdominal pain does not preclude a diagnosis of diverticulitis. The most important initial step in making the correct diagnosis is to have a high index of suspicion when a young patient presents with lower abdominal pain and tenderness.18 Dierential diagnosis The dierential diagnosis is extensive with some common possibilities being acute appendicitis; Crohn's disease; ulcerative colitis; irritable bowel syndrome; pseudomembranous colitis; gynaecological and urological conditions. Investigations Blood tests The initial screening should include blood tests for leukocytosis and in¯ammatory markers. They are useful but may not be uniformly abnormal. One study reported a normal white cell count in 45% of cases with acute diverticulitis.42 CT scans Diverticulitis is an extraluminal disease. Therefore, luminal contrast studies, once the gold standard, may not be the best ®rst line investigation. A number of prospective investigations have reported a sensitivity of 69±95% and a speci®city of 75±100% for CT scanning suggesting superiority over contrast examinations.43±45 For diverticulitis, CT scans have a positive predictive value of 73% for sigmoid diverticula, 88% for pericolic in¯ammation, 100% for wall thickness 4 10 mm and 85% for wall thickness of 7±10 mm.45±50 A CT scan is useful for dierentiating uncomplicated from complicated cases51, which is important since it determines the future management plan. In addition, interventional CT may be a therapeutic tool in diverticulitis.52,53 The diagnostic criteria described on a CT scan are: pericolic in®ltration of fatty tissue, thickening of the colonic wall, extraluminal air and abscess formation (pericolic or distal).2 It is imperative to bear in mind that a negative CT scan does not exclude the diagnosis.
626 N. A. Afzal and M. Thomson
Contrast enema examinations Contrast enema examinations are complementary to CT scans. A water-soluble contrast media may be used instead of barium especially if perforation is suspected or imminent. Diagnostic ®ndings are: the presence of diverticula; mass eect; intramural mass; sinus tract; extravasation of contrast and demonstration of extravasated contrast material outlining an abscess cavity, intramural sinus tract or ®stula.54 Plain abdominal X-rays Plain abdominal X-rays are not helpful and may show non-speci®c bowel dilatation. However, they are useful for excluding ileus, bowel obstruction, soft tissue mass and pneumo-peritoneum, which may occur in 3±12% of patients with acute diverticulitis.55 Ultrasound Ultrasound has been reported to have a sensitivity of 84±98% and speci®city of 80±97%, a positive predictive value of 76% and an accuracy for abscess detection of 90±97%.56±58 One small study has shown ultrasound and CT scan to have comparable results59, another has suggested that CT scans are superior.60 The diagnostic criteria for diverticulitis seen on the ultrasound are: wall thickening; presence of abscess and rigid hyperechogenecity of the colon because of in¯ammation.2 Endoscopy Endoscopy remains the investigation of choice to exclude in¯ammatory bowel disease. However, endoscopy is regarded as a risky procedure in an adult with acute diverticulitis due to the possibility of perforation from air insuation or the instrument itself. It is therefore suggested that it should be avoided in initial evaluation. However, a paediatric colonoscope may allow easier colonic intubation in the presence of diverticulosis. Adolescent in¯ammatory bowel disease is increasing61 and remains an important dierential diagnosis. Endoscopy (upper gastrointestinal and colonoscopy) is important in a stable patient when the diagnosis of in¯ammatory bowel disease is in question. TREATMENT The mainstay treatment for acute uncomplicated diverticulitis is bowel rest and antibiotics. CT scans help to dierentiate complicated from uncomplicated diverticulitis. By de®nition, the absence of an abscess, obstruction, ®stula or free perforation constitutes uncomplicated diverticulitis.2,62 Gram-negative rods (Escherichia coli most commonly) and anaerobes are the usual bacteria in a local infection. Bacteroides fragilis is present in 65±94% of cases with intraabdominal infections.63 Recommended treatment regimens are based on clinical consensus rather than randomized controlled trials. Recommended regimens for anaerobic cover include metronidazole and aminoglycosides or third generation cephalosporins for gram-negative organisms.64,65 A single agent coverage with second generation cephalosporins is also a reasonable choice.65,66 Conservative management of uncomplicated diverticulitis in the young has a successful immediate response rate of 70±100%.10,42,67±69
Diverticular disease in adolescence 627
We suggest hospital admission for all cases of adolescents with diverticulitis for medical management since the disease is not well recognized and has less de®ned diagnostic and management guidelines compared to adults. Also, diverticular disease is thought to be more aggressive in the adolescent and young adult. It may be appropriate that such cases should be admitted and managed in a tertiary paediatric gastroenterological unit. Surgery Although cases 5 40 years of age only constitute 5±10% of the total population diagnosed with diverticular disease, 15±40% of all surgery in this condition is performed in this age group.12 It is a commonly held dogma that urgent surgery on the ®rst admission is needed more often in the young than in the elderly. However, the evidence to support this contention is con¯icting with a variable percentage ranging from 17.2% to 88.8% reported in various studies. Most studies (450 patients) report an urgent surgical incidence of 30±40% (Table 3). Surgery required at ®rst admission is quoted to be 15±30% across all age groups.2,70,71 The commonest indication for urgent surgery in the young is abscess formation and perforation (Table 3). Failure of response to antibiotics, recurrent episodes and bowel obstruction are other indications for surgery. Konvolinka35 found that a per-rectal temperature of 4 37.88C was predictive of the need for surgery. All emergency cases and half of those requiring subsequent surgery had a temperature elevation of more than 37.88C rectally, while all those with a temperature less than 37.88C were successfully treated conservatively. In contrast, Hackford & Veidenheimer found fever to be unpredictive in the evaluation of acute diverticulitis.72 As noted, it is possible that the higher observed rate of complications and the consequent need for surgery in the young may be due to a delay in diagnosis, resulting in a complicated course of the disease12 due to a low index of suspicion and an incorrect initial diagnosis.11,73 COURSE OF PATIENTS TREATED MEDICALLY? After resolution of the ®rst episode of diverticulitis, colonosocopy is recommended in adults mainly in order to identify any co-existent neoplasia. This is an unlikely diagnosis in an adolescent, although in¯ammatory bowel disease does need exclusion. The main controversy is the issue of management of young people after one episode of diverticulitis. It is a common belief that frequency of recurrence in young patients is higher. There are, however, con¯icting reports varying from none to two-thirds needing surgery during follow up. Ouriel & Schwartz10 showed that 55% of the patients initially managed medically required re-admission within 22 months and 43% underwent surgery for complications of the disease. Eusebio & Isenberg9 found surgery was needed in two-thirds of their patients with diverticular disease within 4 years of the initial attack. However, no information is provided on the number of patients requiring surgery after the ®rst successful medical treatment. Chodak et al's study18 included 17 patients treated medically, seven of whom needed surgery. In Vignati et al's group68 32% of the 30 patients required surgery over a 5±9 years follow up68 and in Simonowtiz & Paloyan's study16 only 4 out of the 24 successfully treated patients required continued medical treatment". None required surgery. It has been standard practice to recommend elective surgery in the young patient after one well-documented episode of uncomplicated diverticulitis. Elective early
22 21 63 40 61 29 17 61 17 92 37 33 181 29
12 6 22 10 22 22 7 44 15 16 20 6 34 5
Urgent surgery
% 55 28.6 34.9 25 36 75.9 41.1 72.1 88.2 17.4 54 18.2 18.8 17.2
NR, not recorded; NA, not applicable; Perfs, perforation of the bowel; Abs, abscess.
Minardi et al (2001)84 Marinella & Mustafa (2000)69 Spivak et al (1997)67 Vignati et al (1995)68 Ambrosetti et al (1994)42 Konvolinka (1994)35 Acosta et al (1992)13 Schauer et al (1992)34 Freischlag et al (1986)12 Ouriel & Schwartz (1983)10 Chodak et al (1981)18 Simonowitz & Paloyan (1977)16 Eusebio & Eisenberg (1973)9 Evans & Dawson (1970)85
Reference 3 perfs/2 abscess 1 perfs/3 abscess 4 perfs/6 abscess 2 perfs NA 2 peritonitis/12 abs NA NA 4 perfs/10 abscess 2 perfs/11 abscess NA 6 perfs/abscess 22 abscess/free pus 2 abscess
Operative ®ndings of advanced disease
7 (3 appendicitis) 4 appendicitis 12 (9 appendicitis NR NR 11 NR 25 (appendicitis) 2 (appendicitis) 5 (appendicitis) 9 (appendicitis) 5 7 4
Surgery done for incorrect diagnosis
Table 3. Percentage of cases and type of surgery needed on admission in the young (5 40 years) ± literature review of last 26 years.
628 N. A. Afzal and M. Thomson
Diverticular disease in adolescence 629
surgery carries a low operative risk in the non-in¯amed bowel and avoids the risk of recurrence.39 However, the experience of the condition in the ®rst two to three decades of life is so limited that it is not clear whether there is sucient evidence to date to recommend surgery after the ®rst episode of uncomplicated diverticulitis.2 There is still very little known about the life history of diverticulitis in the young and especially the adolescent.2 COMPLICATIONS OF DIVERTICULAR DISEASE Abscess An abscess may be suspected speci®cally in the context of slow clinical improvement. There may be persistent fever, leukocytosis or a tender mass on examination.2 An abscess results because of perforation of the bowel during an episode of acute diverticulitis which may be localized or extend to form a pericolic or intra-abdominal collection. Pyogenic liver abscesses are a recognized complication of colonic diverticulitis.74 A larger perforation may result in purulent or faecal peritonitis. These can be classi®ed by the degree of perforation (Table 4)51 which is particularly useful in determining management and treatment of the patient. Small pericolic abscesses (Hinchley stage I) are managed conservatively75 whereas larger abscesses (stage II and above) require drainage.2 CT guided drainage is possible in adults52,53 and has been used in children, though for other indications.76 A laparotomy may be a better option especially for multi-loculated poorly responsive abscesses. Simultaneous primary resection of the diseased segment of the gut is recommended.62 Free perforation, although uncommon, carries a 6±35% mortality in adults depending on the degree of faecal contamination, magnitude of sepsis and timing of operative intervention.77±79 There are no data available in children or adolescents.80 Fistulae Colovesical ®stulae are the most common spontaneously occurring ®stulae and comprise 65% of adult diverticular ®stulae.81,82 Other ®stulae may be colovaginal, coloenteric and colouterine. The general principle of management is to resect the diseased segment of colon and repair the contiguous organ. Primary resection and anastomosis is possible in 75% of adults.81,83 Obstruction This is a rare complication of acute diverticulitis in the young and needs surgical intervention after stabilization. Table 4. Hinchley's classi®cation of perforation of bowel in acute diverticulitis. Stage
Description
I II III IV
Diverticulitis associated with pericolic abscess Diverticulitis associated with distant abscess (retroperitonieal or pelvic) Diverticulitis associated with purulent peritonitis Diverticulitis associated with faecal peritonitis
630 N. A. Afzal and M. Thomson
SUMMARY Diverticular disease is uncommon in the young adult and, indeed, rare in the adolescent. Incidental diagnosis of diverticulosis does not warrant any further investigations, although a higher ®bre diet may be useful in this situation. Diverticulitis presents with diagnostic diculty since it is under-recognized and rarely presents with the classical clinical features, most commonly being confused with acute appendicitis. This may best be avoided by simply considering the diagnosis as a potential dierential in any adolescent presenting with acute abdominal pain. CT scan is the best non-invasive investigation.
Practice points . `diverticular disease' is a broad term encompassing diverticulosis, diverticulitis and complications of diverticulitis . the term is generally used for pathology in the large bowel . diverticular disease is uncommon in the young (5 40 years) and rare in adolescents . diverticular disease is commoner in males in the young (5 40 years of age) . diverticular disease has been termed a disease of Western civilization . it is becoming commoner in Asia with the adoption of Western diets . right-sided diverticulitis is commoner in the Asian population compared to leftsided colonic involvement in the West . diverticular disease is acquired in the majority of cases and is associated with a low ®bre diet . obesity has been linked to diverticular disease in the young . asymptomatic diverticulosis does not warrant any further investigations; however, a high ®bre diet may be advisable in such cases . diverticulosis may occasionally produce symptoms that are indistinguishable from those of irritable bowel syndrome . acute diverticulitis is dicult to diagnose in young adolescents . it rarely presents with the classical signs and symptoms . the absence of left-sided abdominal pain does not preclude a diagnosis of diverticulitis . a CT scan may be the most useful non-invasive diagnostic investigation . it is essential to exclude in¯ammatory bowel disease in the young adolescent with symptoms and signs suggestive of diverticulitis . since diverticular disease and diverticulitis are rare in the adolescent, it is dicult to formulate management guidelines . in an acute episode of diverticulitis conservative medical treatment with antibiotics is the treatment of choice. Nevertheless, bowel resection may be required in complicated or recurrent diverticulitis . there is no evidence to support the standard practice of bowel resection after one episode of acute diverticulitis in the young or adolescent patient . perforation and abscesses are a common complication of acute diverticulitis . Hinchley's classi®cation is helpful in planning management . an abscess should be suspected if there is little or no clinical response to medical management
Diverticular disease in adolescence 631
Research agenda . . . . .
the true incidence of diverticular disease in the adolescent remains unknown it is not known why diverticular disease involves the right side of colon in Asians the pathophysiology of diverticular disease in the adolescent is still unclear it is not known if usage of bran halts the progression of diverticular disease very little is known of the life history of diverticular disease in the adolescent
In¯ammatory bowel disease is an important dierential diagnosis to consider in adolescents, in contrast to colonic neoplasia in adults. An upper and lower gastrointestinal endoscopy is warranted once the acute episode has settled. Diverticulitis is more aggressive in the adolescent and young adult with a higher percentage needing surgery. However, not much is known about the life history of the disease and there is little evidence to support the standard practice of surgery after resolution of the ®rst episode. Colonic perforation and abscesses are the commonest complications of an acute episode of diverticulitis.
REFERENCES 1. Otte JJ, Larsen L & Andersen JR. Irritable bowel syndrome and symptomatic diverticular disease ± dierent diseases? American Journal of Gastroenterology 1986; 81: 529±531. * 2. Wong WD, Wexner SD, Lowry A et al. Practice parameters for the treatment of sigmoid diverticulitis ± supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Diseases of the Colon and Rectum 2000; 43: 290±297. 3. Chiu EJ, Shyr YM, Su CH et al. Diverticular disease of the small bowel. Hepatogastroenterology 2000; 47: 181±184. 4. Welch CE, Allen AW & Donaldson GA. An appraisal of resection of the colon for diverticulitis of the sigmoid. Annals of Surgery 1953; 138: 332±343. 5. Pohlman T. Diverticulitis. Gastroenterology Clinics of North America 1988; 17: 357±385. 6. Parks TG. Natural history of diverticular disease of the colon. Clinical Gastroenterology 1975; 4: 53±69. 7. Lee YS. Diverticular disease of the large bowel in Singapore. An autopsy survey. Diseases of the Colon and Rectum 1986; 29: 330±335. 8. Hughes LE. Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis. Gut 1969; 10: 336±344. 9. Eusebio EB & Eisenberg MM. Natural history of diverticular disease of the colon in young patients. American Journal of Surgery 1973; 125: 308±311. *10. Ouriel K & Schwartz SI. Diverticular disease in the young patient. Surgery, Gynecology and Obstetrics 1983; 156: 1±5. 11. Rodkey GV & Welch CE. Changing patterns in the surgical treatment of diverticular disease. Annals of Surgery 1984; 200: 466±478. *12. Freischlag J, Bennion RS & Thompson JE Jr. Complications of diverticular disease of the colon in young people. Diseases of the Colon and Rectum 1986; 29: 639±643. *13. Acosta JA, Grebenc ML, Doberneck RC et al. Colonic diverticular disease in patients 40 years old or younger. American Surgeon 1992; 58: 605±607. 14. Ashurst APC. Sigmoid diverticulitis (mesosigmoiditis) in a child. Annals of Surgery 1908; 47: 300±305. 15. Hartwell JA & Cecil RL. Intestinal diverticula. A pathological and clinical study. American Journal of the Medical Sciences 1910; 140: 174±203. 16. Simonowitz D & Paloyan D. Diverticular disease of the colon in patients under 40 years of age. American Journal of Gastroenterology 1977; 67: 69±72. 17. Feczko PJ, Nish AD, Craig BM & Simms SM. Acute diverticulitis in patients under 40 years of age: radiologic diagnosis. American Journal of Roentgenology 1988; 150: 1311±1314. *18. Chodak GW, Rangel DM & Passaro E Jr. Colonic diverticulitis in patients under age 40: need for earlier diagnosis. American Journal of Surgery 1981; 141: 699±702.
632 N. A. Afzal and M. Thomson 19. Milsom JW & Singh G. Diverticulitis in young patients. Seminars in Colon and Rectal Surgery 1990; 1: 103±108. 20. Rankin FW & Brown PW. Diverticulitis of the colon. Surgery, Gynecology and Obstetrics 1930; 50: 836±839. 21. Painter NS & Burkitt DP. Diverticular disease of the colon: a de®ciency disease of Western civilization. British Medical Journal 1971; 2: 450±454. 22. Painter NS. Diverticular disease of the colon ± a disease of the century. Lancet 1969; ii: 586±588. 23. Segal I, Solomon A & Hunt JA. Emergence of diverticular disease in the urban South African black. Gastroenterology 1977; 72: 215±219. 24. Sugihara K, Muto T, Morioka Y et al. Diverticular disease of the colon in Japan. A review of 615 cases. Diseases of the Colon and Rectum 1984; 27: 531±537. 25. Munakata A, Nakaji S, Yoshida Y et al. Study on the diverticular disease of the colon in Korea. Journal of the Japan Society of Coloproctology 1982; 35: 224±231. 26. Vajrabukka T, Saksornchai K & Jimakorn P. Diverticular disease of the colon in a far-eastern community. Diseases of the Colon and Rectum 1980; 23: 151±154. 27. Stemmermann GN & Yatani R. Diverticulosis and polyps of the large intestine. A necropsy study of Hawaii Japanese. Cancer 1973; 31: 1260±1270. 28. Clunie GJA & Mason JM. Visceral diverticula and the Marfan syndrome. British Journal of Surgery 1962; 50: 51±52. 29. Mielke JE, Becker KL & Gross JB. Diverticulitis of the colon in a young man with Marfan's syndrome. Gastroenterology 1965; 48: 379±382. 30. Whiteway J & Morson BC. Elastosis in diverticular disease of the sigmoid colon. Gut 1985; 26: 258±266. 31. Smith AN. Colonic muscle in diverticular disease. Clinical Gastroenterology 1986; 15: 917±935. 32. Aldoori WH, Giovannucci EL, Rockett HR et al. A prospective study of dietary ®ber types and symptomatic diverticular disease in men. Journal of Nutrition 1998; 128: 714±719. 33. Aldoori WH, Giovannucci EL, Rimm EB et al. Prospective study of physical activity and the risk of symptomatic diverticular disease in men. Gut 1995; 36: 276±282. *34. Schauer PR, Ramos R, Ghiatas AA & Sirinek KR. Virulent diverticular disease in young obese men. American Journal of Surgery 1992; 164: 443±446. *35. Konvolinka CW. Acute diverticulitis under age forty. American Journal of Surgery 1994; 167: 562±565. 36. Murayama N, Baba S, Kodaira S & Abe O. An aetiological study of diverticulosis of the right colon. Australian and New Zealand Journal of Surgery 1981; 51: 420±425. 37. Sugihara K, Muto T & Morioka Y. Motility study in right sided diverticular disease of the colon. Gut 1983; 24: 1130±1134. 38. Schapira A, Leichtling JJ, Wolf BS et al. Diverticulitis of the cecum and right colon: clinical and radiographic features. American Journal of Digestive Diseases 1958; 3: 351±383. 39. Stollman NH & Raskin JB. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. American Journal of Gastroenterology 1999; 94: 3110±3121. 40. Greaney EM & Snyder WH. Acute diverticulitis of the cecum encountered at emergency surgery. American Journal of Surgery 1957; 94: 270±281. 41. Wagner DE & Zollinger RW. Diverticulitis of the cecum and ascending colon. Archives of Surgery 1961; 83: 124±129. *42. Ambrosetti P, Robert JH, Witzig JA et al. Acute left colonic diverticulitis in young patients. Journal of the American College of Surgeons 1994; 179: 156±160. 43. Morris J, Stellato TA, Lieberman J & Haaga JR. The utility of computed tomography in colonic diverticulitis. Annals of Surgery 1986; 204: 128±132. 44. Smith TR, Cho KC, Morehouse HT & Kratka PS. Comparison of computed tomography and contrast enema evaluation of diverticulitis. Diseases of the Colon and Rectum 1990; 33: 1±6. 45. Doringer E. Computerized tomography of colonic diverticulitis. Critical Reviews in Diagnostic Imaging 1992; 33: 421±435. 46. Hulnick DH, Megibow AJ, Balthazar EJ et al. Computed tomography in the evaluation of diverticulitis. Radiology 1984; 152: 491±495. 47. Cho KC, Morehouse HT, Alterman DD & Thornhill BA. Sigmoid diverticulitis: diagnostic role of CT ± comparison with barium enema studies. Radiology 1990; 176: 111±115. 48. Stefansson T, Nyman R, Nilsson S et al. Diverticulitis of the sigmoid colon. A comparison of CT, colonic enema and laparoscopy. Acta Radiologica 1997; 38: 313±319. 49. Ambrosetti P, Jenny A, Becker C et al. Acute left colonic diverticulitis ± compared performance of computed tomography and water-soluble contrast enema: prospective evaluation of 420 patients. Diseases of the Colon and Rectum 2000; 43: 1363±1367. 50. Ambrosetti P, Grossholz M, Becker C et al. Computed tomography in acute left colonic diverticulitis. British Journal of Surgery 1997; 84: 532±534.
Diverticular disease in adolescence 633 51. Hinchey EJ, Schaal PG & Richards GK. Treatment of perforated diverticular disease of the colon. Advances in Surgery 1978; 12: 85±109. 52. Schechter S, Eisenstat TE, Oliver GC et al. Computerized tomographic scan-guided drainage of intraabdominal abscesses. Preoperative and postoperative modalities in colon and rectal surgery. Diseases of the Colon and Rectum 1994; 37: 984±988. 53. Stabile BE, Puccio E, vanSonnenberg E & Ne CC. Preoperative percutaneous drainage of diverticular abscesses. American Journal of Surgery 1990; 159: 99±104. 54. Duma RJ & Kellum JM. Colonic diverticulitis: microbiologic, diagnostic, and therapeutic considerations. Current Clinical Topics in Infectious Diseases 1991; 11: 218±247. 55. McKee RF, Deignan RW & Krukowski ZH. Radiological investigation in acute diverticulitis. British Journal of Surgery 1993; 80: 560±565. 56. Verbanck J, Lambrecht S, Rutgeerts L et al. Can sonography diagnose acute colonic diverticulitis in patients with acute intestinal in¯ammation? A prospective study. Journal of Clinical Ultrasound 1989; 17: 661±666. 57. Schwerk WB, Schwarz S & Rothmund M. Sonography in acute colonic diverticulitis. A prospective study. Diseases of the Colon and Rectum 1992; 35: 1077±1084. 58. Zielke A, Hasse C, Bandorski T et al. Diagnostic ultrasound of acute colonic diverticulitis by surgical residents. Surgical Endoscopy 1997; 11: 1194±1197. 59. Pradel JA, Adell JF, Taourel P et al. Acute colonic diverticulitis: prospective comparative evaluation with US and CT. Radiology 1997; 205: 503±512. 60. Eggesbo HB, Jacobsen T, Kolmannskog F et al. Diagnosis of acute left-sided colonic diverticulitis by three radiological modalities. Acta Radiologica 1998; 39: 315±321. 61. Sawczenko A, Sandhu BK, Logan RF et al. Prospective survey of childhood in¯ammatory bowel disease in the British Isles. Lancet 2001; 357: 1093±1094. 62. Roberts P, Abel M, Rosen L et al. Practice parameters for sigmoid diverticulitis. The Standards Task Force American Society of Colon and Rectal Surgeons. Diseases of the Colon and Rectum 1995; 38: 125±132. 63. Nichols RL. Management of intra-abdominal sepsis. American Journal of Medicine 1986; 80(6B): 204±209. 64. Chow AW. Appendicitis and diverticulitis. In Hoeprich PD, Jordan MC & Ronald AR (eds) Infectious Diseases: A Treatise of Infectious Processes, pp 878±881. Philadelphia: JB Lippencott, 1994. 65. Nadel S, Heyderman R & Klein N. Therapeutic guidelines in Paediatric Infections, 1st edn. London: Chapman and Hall Medical, 1996. 66. Kellum JM, Sugerman HJ, Coppa GF et al. Randomized, prospective comparison of cefoxitin and gentamicin±clindamycin in the treatment of acute colonic diverticulitis. Clinical Therapeutics 1992; 14: 376±384. *67. Spivak H, Weinrauch S, Harvey JC et al. Acute colonic diverticulitis in the young. Diseases of the Colon and Rectum 1997; 40: 570±574. 68. Vignati PV, Welch JP & Cohen JL. Long-term management of diverticulitis in young patients. Diseases of the Colon and Rectum 1995; 38: 627±629. *69. Marinella MA & Mustafa M. Acute diverticulitis in patients 40 years of age and younger. American Journal of Emergency Medicine 2000; 18: 140±142. 70. Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. British Medical Journal 1969; 4: 639±642. 71. Almy TP & Howell DA. Medical progress. Diverticular disease of the colon. New England Journal of Medicine 1980; 302: 324±331. 72. Hackford AW & Veidenheimer MC. Diverticular disease of the colon. Current concepts and management. Surgical Clinics of North America 1985; 65: 347±363. 73. Colcock BP. Surgical management of diverticulitis. Surgery, Gynecology and Obstetrics 1958; 102: 721±726. 74. Yoshida M, Mitsuo M, Kutsumi H et al. A successfully treated case of multiple liver abscesses accompanied by portal venous gas. American Journal of Gastroenterology 1996; 91: 2423±2425. 75. Ambrosetti P, Robert J, Witzig JA et al. Incidence, outcome, and proposed management of isolated abscesses complicating acute left-sided colonic diverticulitis. A prospective study of 140 patients. Diseases of the Colon and Rectum 1992; 35: 1072±1076. 76. Gervais DA, Hahn PF, O'Neill MJ & Mueller PR. CT-guided transgluteal drainage of deep pelvic abscesses in children: selective use as an alternative to transrectal drainage. American Journal of Roentgenology 2000; 175: 1393±1396. 77. Auguste L, Borrero E & Wise L. Surgical management of perforated colonic diverticulitis. Archives of Surgery 1985; 120: 450±452. 78. Hackford AW, Schoetz DJ Jr, Coller JA & Veidenheimer MC. Surgical management of complicated diverticulitis. The Lahey Clinic experience, 1967 to 1982. Diseases of the Colon and Rectum 1985; 28: 317±321.
634 N. A. Afzal and M. Thomson 79. Nagorney DM, Adson MA & Pemberton JH. Sigmoid diverticulitis with perforation and generalized peritonitis. Diseases of the Colon and Rectum 1985; 28: 71±75. 80. Read DR & Hambrick E. Hepatic abscesses in diverticulitis. Southern Medical Journal 1980; 73: 881±883. 81. Woods RJ, Lavery IC, Fazio VW et al. Internal ®stulas in diverticular disease. Diseases of the Colon and Rectum 1988; 31: 591±596. 82. Pontari MA, McMillen MA, Garvey RH & Ballantyne GH. Diagnosis and treatment of enterovesical ®stulae. American Surgeon 1992; 58: 258±263. 83. McBeath RB, Schi M Jr, Allen V et al. A 12-year experience with enterovesical ®stulas. Urology 1994; 44: 661±665. 84. Minardi AJ Jr, Johnson LW, Sehon JK et al. Diverticulitis in the young patient. American Surgeon 2001; 67: 458±461. 85. Evans WE & Dawson RG. Diverticulitis in the young adult. American Surgeon 1970; 36: 518±521. 86. Kim U & Dreiling DA. Problems in the diagnosis of diverticulitis in the young. American Journal of Gastroenterology 1974; 62: 109±115.
doi:10.1053/bega.2002.0303, available online at http://www.idealibrary.com on
7 Diverticular disease in adolescence Nadeem Ahmad Afzal
MRCPCH, MRCP
Research Fellow and Honorary Specialist Registrar in Paediatric Gastroenterology
Mike Thomson
FRCPCH, MD
Clinical Director and Consultant in Paediatric Gastroenterology Centre for Paediatric Gastroenterology, Royal Free Hospital, Pond Street, Hampstead, London, NW3 2QG, UK
Diverticular disease is rare in the adolescent. Acute diverticulitis is almost never considered as a diagnosis for a young patient presenting with abdominal pain. Unfortunately, unrecognized it may be associated with signi®cant morbidity and mortality. Also, when present, diverticulitis in the young adult is considered to be more aggressive compared to diverticulitis in older adults. Therefore, it is important to recognize, diagnose and manage diverticular disease appropriately in this age group. In tis chapter we will review the available literature on diverticula disease in the adolescent and youn adult, discuss epidemilogy, aetiology and pathogenesis and suggest guidelines for diagnosis and management. Key words: diverticular disease; diverticulitis; diverticulosis; colon; large bowel; young adult; adolescent.
Diverticula, when present, may exist in the small or large intestine. However, the term `diverticular disease' is commonly used for pathology in the large intestine only. Diverticular disease of the large bowel is a very broad term, encompassing diverticulosis, diverticulitis and complicated diverticulitis. The term diverticular disease is also used interchangeably with diverticulitis, which is incorrect. Diverticulosis signi®es the presence of diverticula without any in¯ammation. Non-speci®c bowel symptoms may be present, which overlap considerably with those of irritable bowel syndrome.1 Conversely, diverticulitis is de®ned as the presence of in¯ammation or infection associated with diverticula.2 It is an acute abdominal condition necessitating prompt treatment and emergency surgery in some cases. When associated with obstruction, stricture, ®stula or abscess it is known as complicated diverticulitis.2 Diverticular disease of the small intestine, excepting Meckel's diverticulum, is not uncommon. However, diverticula when present in the small intestine are most frequently present in the duodenum. Small bowel diverticula, except for Meckel's, require no intervention if no signi®cant symptoms are found.3 In this chapter we will address diverticular disease in the large bowel in the adolescent and the young adult (540 years). All correspondence to M. Thomson. Tel: 00 44 207 830 2779; Fax: 00 44 207 830 2146, E-mail: m.thomson @rfc. ucl.ac.uk c 2002 Published by Elsevier Science Ltd. 1521±6918/02/$ - see front matter *
622 N. A. Afzal and M. Thomson
INCIDENCE AND PREVALENCE Diverticulosis occurs in one-third of the population over the age of 45 and in up to twothirds of the population over 85 years of age.4 Of the patients with diverticulosis, 10±25% will progress to diverticulitis.5,6 The true incidence of diverticulosis is not accurately known as it is invariably asymptomatic. In a review of 2000 barium enema studies in patients less than 35 years of age, not one case of diverticulosis was found.4 Lee studied 1014 colons at post-mortem and found evidence of diverticula from the second decade of life, with 6% of the total showing diverticular disease below 40 years of age.7 A post-mortem series of 200 patients by Hughes8 showed diverticular disease in 9% of cases less than 50 years of age but again no diverticula were seen below 30 years of age. Within the total population with diverticular disease, the young (540 years of age) comprise only 2±7%.9±11 However, others have reported an incidence of between 20±29%.12,13 In these studies the incidence was calculated by only using cases of acute diverticulitis as the denominator for calculation, rather than all cases of diverticular disease, possibly accounting for the higher reported incidence. It is also possible that there may be some under-reporting, since not all cases of young people with abdominal pain are investigated speci®cally for diverticular disease.10 Diverticular disease was ®rst reported in a child in 1908 and, subsequently, there have been only rare cases reported in adolescents.14,15 Table 1 summarizes a series of studies published on diverticular disease in those under 40 years of age over the last 26 years. There have been only two reported cases in adolescents.
SEX DISTRIBUTION Diverticular disease is more common in males than females under 40 years of age4,10,12,16±18, although diverticular disease in all age groups is commoner in females.19 This seems to have changed from a male predominance in the earlier part of the 20th century.20 The reasons for this are unknown.
Table 1. Diverticular disease in the young and adolescents; a review of studies in the last 26 years. Reference
Patients 84
Minardi et al (2001) Marinella & Mustafa (2000)69 Spivak et al (1997)67 Vignati et al (1995)68 Ambrosetti et al (1994)42 Konvolinka (1994)35 Acosta et al (1992)13 Schauer et al (1992)34 Freischlag et al (1986)12 Ouriel & Schwartz (1983)10 Chodak et al (1981)18 Simonowitz & Paloyan (1977)16 Eusebio & Eisenberg (1973)9 Ave, average; NR, not recorded.
22 21 63 40 61 29 17 61 17 92 37 33 181
Age 540 540 545 550 550 540 540 540 540 540 540 540 540
(16±40) (mean 34) (27±45) (ave 38) (24±50) (19±39) (23±40) (28±38) (15±40) (21±40) (24±40)
Adolescents 1 None None NR None None None NR None 1 None None None
Diverticular disease in adolescence 623
SOCIO-DEMOGRAPHIC DISTRIBUTION Diverticular disease has been termed a disease of Western civilization. The highest incidences are seen in the UK, the USA, Europe and Australia, but rare in rural Africa and Asia.21,22 However, with the adoption of Western dietary habits (low ®bre) there have been more recent reports from Africa23, Japan24 and Singapore.7 Furthermore, right-sided disease (involvement of the caecum and the ascending colon) is more prevalent in the Asian population7,24±26 compared with left-sided disease (sigmoid and descending colon) in the Western world. Interestingly right-sided disease is also common in those of Japanese descent living in Hawaii.27 AETIOLOGY AND PATHOGENESIS Diverticular disease is common in the elderly and rare in the young. However, certain connective tissue disorders such as Marfan's syndrome28,29 and also the use of steroids6, may predispose to the development of diverticular disease earlier in life. These observations led to an erroneous conclusion that all individuals developing diverticulitis may have a collagen de®ciency in their colons, as seen in Marfan's syndrome patients in whom it was postulated that the colon could be predisposed to mucosal herniation leading to diverticulosis. However, subsequent electron microscopy studies in diverticulosis have shown structurally normal muscle cells in the colon wall, with elastin deposition of twice the normal amount between the muscle cells in the taenia.30 Fibre intake is thought to be an important factor in the evolution of diverticulosis. Fibre ®lls the colon with bulkier, moister faeces, which necessitate less work for the colon. Simply it operates as a low-pressure system, only occasionally evacuating by mass peristalsis into the rectum. Population studies show that diverticular disease subjects consume less ®bre resulting in decreased faecal mass, slower transit with decreased output causing increased pressure generation in the colon in an attempt to propel the faecal mass. Consequently, there is a change in colonic wall compliance, which may occur because of collagen failure. Elastosis may result, causing contraction of the taeniae. This produces the typical contracted structure seen in the excised colonic specimen31, and is perhaps one of the explanations for the changes seen under the electron microscope in diverticulosis. Fibre intake has been found to be inversely proportional to diverticular disease in a prospective follow-up of 51, 259 male health professionals in the USA.32 Over a 6-year period 385 new cases of symptomatic diverticular disease were identi®ed. A signi®cant inverse association was found between insoluble dietary ®bre intake and the risk of subsequently developing symptomatic diverticular disease.33 Schauer et al and Konvolinka have reported obesity to be signi®cantly related to diverticular disease in the young. These patients had so called `diverticulogenic' diets.34,35 Obesity may be the result of increased carbohydrate and decreased ®bre in the diet. Obesity has been associated with diverticular disease in young Hispanic men34 and this problem may also be addressed with a high ®bre diet. The pathogenesis of right-sided diverticular disease is less clear. As in left-sided diverticulitis, thickening of the taenia coli and inner circular muscle is present in rightsided diverticulitis, although to a lesser degree.36 Motility and intra-luminal studies also suggest that high intraluminal pressure and abnormal motility in the ascending colon may be important in the pathogenesis of right-sided diverticula disease.37 All diverticula examined histologically, including cases of single diverticulum, that were previously
624 N. A. Afzal and M. Thomson
believed to be congenital38 were shown to be acquired and caused by herniation of the mucosa through the muscle coat.7,8 Therefore, solitary or multiple diverticulosis on the right or left side of the colon are most likely part of the spectrum of the same disease, with perhaps some in¯uence of genetics and race.7 DIVERTICULOSIS Diverticulosis is asymptomatic but, rarely, may produce symptoms. Therefore, it may only be diagnosed incidentally on barium studies, colonoscopy, or computer tomography (CT) scanning. The presence of diverticula in an asymptomatic patient does not require any further diagnostic evaluation.39 However, it is reasonable to advise a high ®bre diet (see Aetiology and Pathogenesis, above). Patients with diverticulosis may present with lower abdominal pain and with symptoms similar to irritable bowel syndrome. When an adolescent presents with such symptoms the dierential diagnosis is long and warrants a thorough history and examination including determination of growth parameters and pubertal development. In addition, blood tests, which include a full blood count, liver function tests, in¯ammatory markers and coeliac screen, are recommended. Bowel cancer is a main dierential diagnosis in the adult, but is much less likely in an adolescent. There are no randomized controlled trials supporting a role for anti-spasmodics, as advised in the past, and de®nitely no role for antibiotics in the absence of diverticulitis.39 DIVERTICULITIS There are two reasons why it is hard to make a diagnosis of acute diverticulitis in the young. Firstly, diverticulitis is uncommon in the young and rare in the adolescent, hence it is rarely considered in the list of dierential diagnoses of acute abdominal pain. Secondly, the classical features of acute diverticulitis are reported to be present in 535%. Table 2 lists the percentage of reported misdiagnoses. The percentage of misdiagnoses is further increased to more than 90% in right-sided diverticulitis (caecum and ascending colon)40,41 as it may be confused with acute appendicitis (Table 2).
Table 2. Accuracy of diagnosis of acute diverticulitis in the young. Reference
Misdiagnosis (no. of cases) 84
Minardi et al (2001) Marinella & Mustafa (2000)69 Spivak et al (1997)67 Konvolinka (1994)35 Schauer et al (1992)34 Freischlag et al (1986)12 Ouriel & Schwartz (1983)10 Chodak et al (1981)18 Eusebio & Eisenberg (1973)9 Simonowitz & Paloyan (1977)16 Evans & Dawson (1970)85 Kim & Dreiling (1974)86
13 10 28 15 25 8 47 22 56 24 4 3
% 59 48 44 50 41 47 51 63 88 73 44 60
Diverticular disease in adolescence 625
Clinical manifestations of diverticulitis in the young It is reported that 5 35% of young patients present with the known classical features of diverticulitis i.e. fever, leukocytosis, left lower quadrant abdominal pain, mass and tenderness.12,34,35 The commonest presenting features are as follows: 1. Fever (73±90%). 2. Abdominal pain (70±92%), not present on the left side in half of the cases and it may be intermittent or constant. 3. Nausea and vomiting (62%). 4. Diarrhoea (24%). 5. Palpable mass in the abdomen (13±24%). 6. Abdominal tenderness and guarding (80%), although rarely left side alone. 7. Leukocytosis (4 10 106/l).10,12,18,35 Hence the absence of left-sided abdominal pain does not preclude a diagnosis of diverticulitis. The most important initial step in making the correct diagnosis is to have a high index of suspicion when a young patient presents with lower abdominal pain and tenderness.18 Dierential diagnosis The dierential diagnosis is extensive with some common possibilities being acute appendicitis; Crohn's disease; ulcerative colitis; irritable bowel syndrome; pseudomembranous colitis; gynaecological and urological conditions. Investigations Blood tests The initial screening should include blood tests for leukocytosis and in¯ammatory markers. They are useful but may not be uniformly abnormal. One study reported a normal white cell count in 45% of cases with acute diverticulitis.42 CT scans Diverticulitis is an extraluminal disease. Therefore, luminal contrast studies, once the gold standard, may not be the best ®rst line investigation. A number of prospective investigations have reported a sensitivity of 69±95% and a speci®city of 75±100% for CT scanning suggesting superiority over contrast examinations.43±45 For diverticulitis, CT scans have a positive predictive value of 73% for sigmoid diverticula, 88% for pericolic in¯ammation, 100% for wall thickness 4 10 mm and 85% for wall thickness of 7±10 mm.45±50 A CT scan is useful for dierentiating uncomplicated from complicated cases51, which is important since it determines the future management plan. In addition, interventional CT may be a therapeutic tool in diverticulitis.52,53 The diagnostic criteria described on a CT scan are: pericolic in®ltration of fatty tissue, thickening of the colonic wall, extraluminal air and abscess formation (pericolic or distal).2 It is imperative to bear in mind that a negative CT scan does not exclude the diagnosis.
626 N. A. Afzal and M. Thomson
Contrast enema examinations Contrast enema examinations are complementary to CT scans. A water-soluble contrast media may be used instead of barium especially if perforation is suspected or imminent. Diagnostic ®ndings are: the presence of diverticula; mass eect; intramural mass; sinus tract; extravasation of contrast and demonstration of extravasated contrast material outlining an abscess cavity, intramural sinus tract or ®stula.54 Plain abdominal X-rays Plain abdominal X-rays are not helpful and may show non-speci®c bowel dilatation. However, they are useful for excluding ileus, bowel obstruction, soft tissue mass and pneumo-peritoneum, which may occur in 3±12% of patients with acute diverticulitis.55 Ultrasound Ultrasound has been reported to have a sensitivity of 84±98% and speci®city of 80±97%, a positive predictive value of 76% and an accuracy for abscess detection of 90±97%.56±58 One small study has shown ultrasound and CT scan to have comparable results59, another has suggested that CT scans are superior.60 The diagnostic criteria for diverticulitis seen on the ultrasound are: wall thickening; presence of abscess and rigid hyperechogenecity of the colon because of in¯ammation.2 Endoscopy Endoscopy remains the investigation of choice to exclude in¯ammatory bowel disease. However, endoscopy is regarded as a risky procedure in an adult with acute diverticulitis due to the possibility of perforation from air insuation or the instrument itself. It is therefore suggested that it should be avoided in initial evaluation. However, a paediatric colonoscope may allow easier colonic intubation in the presence of diverticulosis. Adolescent in¯ammatory bowel disease is increasing61 and remains an important dierential diagnosis. Endoscopy (upper gastrointestinal and colonoscopy) is important in a stable patient when the diagnosis of in¯ammatory bowel disease is in question. TREATMENT The mainstay treatment for acute uncomplicated diverticulitis is bowel rest and antibiotics. CT scans help to dierentiate complicated from uncomplicated diverticulitis. By de®nition, the absence of an abscess, obstruction, ®stula or free perforation constitutes uncomplicated diverticulitis.2,62 Gram-negative rods (Escherichia coli most commonly) and anaerobes are the usual bacteria in a local infection. Bacteroides fragilis is present in 65±94% of cases with intraabdominal infections.63 Recommended treatment regimens are based on clinical consensus rather than randomized controlled trials. Recommended regimens for anaerobic cover include metronidazole and aminoglycosides or third generation cephalosporins for gram-negative organisms.64,65 A single agent coverage with second generation cephalosporins is also a reasonable choice.65,66 Conservative management of uncomplicated diverticulitis in the young has a successful immediate response rate of 70±100%.10,42,67±69
Diverticular disease in adolescence 627
We suggest hospital admission for all cases of adolescents with diverticulitis for medical management since the disease is not well recognized and has less de®ned diagnostic and management guidelines compared to adults. Also, diverticular disease is thought to be more aggressive in the adolescent and young adult. It may be appropriate that such cases should be admitted and managed in a tertiary paediatric gastroenterological unit. Surgery Although cases 5 40 years of age only constitute 5±10% of the total population diagnosed with diverticular disease, 15±40% of all surgery in this condition is performed in this age group.12 It is a commonly held dogma that urgent surgery on the ®rst admission is needed more often in the young than in the elderly. However, the evidence to support this contention is con¯icting with a variable percentage ranging from 17.2% to 88.8% reported in various studies. Most studies (450 patients) report an urgent surgical incidence of 30±40% (Table 3). Surgery required at ®rst admission is quoted to be 15±30% across all age groups.2,70,71 The commonest indication for urgent surgery in the young is abscess formation and perforation (Table 3). Failure of response to antibiotics, recurrent episodes and bowel obstruction are other indications for surgery. Konvolinka35 found that a per-rectal temperature of 4 37.88C was predictive of the need for surgery. All emergency cases and half of those requiring subsequent surgery had a temperature elevation of more than 37.88C rectally, while all those with a temperature less than 37.88C were successfully treated conservatively. In contrast, Hackford & Veidenheimer found fever to be unpredictive in the evaluation of acute diverticulitis.72 As noted, it is possible that the higher observed rate of complications and the consequent need for surgery in the young may be due to a delay in diagnosis, resulting in a complicated course of the disease12 due to a low index of suspicion and an incorrect initial diagnosis.11,73 COURSE OF PATIENTS TREATED MEDICALLY? After resolution of the ®rst episode of diverticulitis, colonosocopy is recommended in adults mainly in order to identify any co-existent neoplasia. This is an unlikely diagnosis in an adolescent, although in¯ammatory bowel disease does need exclusion. The main controversy is the issue of management of young people after one episode of diverticulitis. It is a common belief that frequency of recurrence in young patients is higher. There are, however, con¯icting reports varying from none to two-thirds needing surgery during follow up. Ouriel & Schwartz10 showed that 55% of the patients initially managed medically required re-admission within 22 months and 43% underwent surgery for complications of the disease. Eusebio & Isenberg9 found surgery was needed in two-thirds of their patients with diverticular disease within 4 years of the initial attack. However, no information is provided on the number of patients requiring surgery after the ®rst successful medical treatment. Chodak et al's study18 included 17 patients treated medically, seven of whom needed surgery. In Vignati et al's group68 32% of the 30 patients required surgery over a 5±9 years follow up68 and in Simonowtiz & Paloyan's study16 only 4 out of the 24 successfully treated patients required continued medical treatment". None required surgery. It has been standard practice to recommend elective surgery in the young patient after one well-documented episode of uncomplicated diverticulitis. Elective early
22 21 63 40 61 29 17 61 17 92 37 33 181 29
12 6 22 10 22 22 7 44 15 16 20 6 34 5
Urgent surgery
% 55 28.6 34.9 25 36 75.9 41.1 72.1 88.2 17.4 54 18.2 18.8 17.2
NR, not recorded; NA, not applicable; Perfs, perforation of the bowel; Abs, abscess.
Minardi et al (2001)84 Marinella & Mustafa (2000)69 Spivak et al (1997)67 Vignati et al (1995)68 Ambrosetti et al (1994)42 Konvolinka (1994)35 Acosta et al (1992)13 Schauer et al (1992)34 Freischlag et al (1986)12 Ouriel & Schwartz (1983)10 Chodak et al (1981)18 Simonowitz & Paloyan (1977)16 Eusebio & Eisenberg (1973)9 Evans & Dawson (1970)85
Reference 3 perfs/2 abscess 1 perfs/3 abscess 4 perfs/6 abscess 2 perfs NA 2 peritonitis/12 abs NA NA 4 perfs/10 abscess 2 perfs/11 abscess NA 6 perfs/abscess 22 abscess/free pus 2 abscess
Operative ®ndings of advanced disease
7 (3 appendicitis) 4 appendicitis 12 (9 appendicitis NR NR 11 NR 25 (appendicitis) 2 (appendicitis) 5 (appendicitis) 9 (appendicitis) 5 7 4
Surgery done for incorrect diagnosis
Table 3. Percentage of cases and type of surgery needed on admission in the young (5 40 years) ± literature review of last 26 years.
628 N. A. Afzal and M. Thomson
Diverticular disease in adolescence 629
surgery carries a low operative risk in the non-in¯amed bowel and avoids the risk of recurrence.39 However, the experience of the condition in the ®rst two to three decades of life is so limited that it is not clear whether there is sucient evidence to date to recommend surgery after the ®rst episode of uncomplicated diverticulitis.2 There is still very little known about the life history of diverticulitis in the young and especially the adolescent.2 COMPLICATIONS OF DIVERTICULAR DISEASE Abscess An abscess may be suspected speci®cally in the context of slow clinical improvement. There may be persistent fever, leukocytosis or a tender mass on examination.2 An abscess results because of perforation of the bowel during an episode of acute diverticulitis which may be localized or extend to form a pericolic or intra-abdominal collection. Pyogenic liver abscesses are a recognized complication of colonic diverticulitis.74 A larger perforation may result in purulent or faecal peritonitis. These can be classi®ed by the degree of perforation (Table 4)51 which is particularly useful in determining management and treatment of the patient. Small pericolic abscesses (Hinchley stage I) are managed conservatively75 whereas larger abscesses (stage II and above) require drainage.2 CT guided drainage is possible in adults52,53 and has been used in children, though for other indications.76 A laparotomy may be a better option especially for multi-loculated poorly responsive abscesses. Simultaneous primary resection of the diseased segment of the gut is recommended.62 Free perforation, although uncommon, carries a 6±35% mortality in adults depending on the degree of faecal contamination, magnitude of sepsis and timing of operative intervention.77±79 There are no data available in children or adolescents.80 Fistulae Colovesical ®stulae are the most common spontaneously occurring ®stulae and comprise 65% of adult diverticular ®stulae.81,82 Other ®stulae may be colovaginal, coloenteric and colouterine. The general principle of management is to resect the diseased segment of colon and repair the contiguous organ. Primary resection and anastomosis is possible in 75% of adults.81,83 Obstruction This is a rare complication of acute diverticulitis in the young and needs surgical intervention after stabilization. Table 4. Hinchley's classi®cation of perforation of bowel in acute diverticulitis. Stage
Description
I II III IV
Diverticulitis associated with pericolic abscess Diverticulitis associated with distant abscess (retroperitonieal or pelvic) Diverticulitis associated with purulent peritonitis Diverticulitis associated with faecal peritonitis
630 N. A. Afzal and M. Thomson
SUMMARY Diverticular disease is uncommon in the young adult and, indeed, rare in the adolescent. Incidental diagnosis of diverticulosis does not warrant any further investigations, although a higher ®bre diet may be useful in this situation. Diverticulitis presents with diagnostic diculty since it is under-recognized and rarely presents with the classical clinical features, most commonly being confused with acute appendicitis. This may best be avoided by simply considering the diagnosis as a potential dierential in any adolescent presenting with acute abdominal pain. CT scan is the best non-invasive investigation.
Practice points . `diverticular disease' is a broad term encompassing diverticulosis, diverticulitis and complications of diverticulitis . the term is generally used for pathology in the large bowel . diverticular disease is uncommon in the young (5 40 years) and rare in adolescents . diverticular disease is commoner in males in the young (5 40 years of age) . diverticular disease has been termed a disease of Western civilization . it is becoming commoner in Asia with the adoption of Western diets . right-sided diverticulitis is commoner in the Asian population compared to leftsided colonic involvement in the West . diverticular disease is acquired in the majority of cases and is associated with a low ®bre diet . obesity has been linked to diverticular disease in the young . asymptomatic diverticulosis does not warrant any further investigations; however, a high ®bre diet may be advisable in such cases . diverticulosis may occasionally produce symptoms that are indistinguishable from those of irritable bowel syndrome . acute diverticulitis is dicult to diagnose in young adolescents . it rarely presents with the classical signs and symptoms . the absence of left-sided abdominal pain does not preclude a diagnosis of diverticulitis . a CT scan may be the most useful non-invasive diagnostic investigation . it is essential to exclude in¯ammatory bowel disease in the young adolescent with symptoms and signs suggestive of diverticulitis . since diverticular disease and diverticulitis are rare in the adolescent, it is dicult to formulate management guidelines . in an acute episode of diverticulitis conservative medical treatment with antibiotics is the treatment of choice. Nevertheless, bowel resection may be required in complicated or recurrent diverticulitis . there is no evidence to support the standard practice of bowel resection after one episode of acute diverticulitis in the young or adolescent patient . perforation and abscesses are a common complication of acute diverticulitis . Hinchley's classi®cation is helpful in planning management . an abscess should be suspected if there is little or no clinical response to medical management
Diverticular disease in adolescence 631
Research agenda . . . . .
the true incidence of diverticular disease in the adolescent remains unknown it is not known why diverticular disease involves the right side of colon in Asians the pathophysiology of diverticular disease in the adolescent is still unclear it is not known if usage of bran halts the progression of diverticular disease very little is known of the life history of diverticular disease in the adolescent
In¯ammatory bowel disease is an important dierential diagnosis to consider in adolescents, in contrast to colonic neoplasia in adults. An upper and lower gastrointestinal endoscopy is warranted once the acute episode has settled. Diverticulitis is more aggressive in the adolescent and young adult with a higher percentage needing surgery. However, not much is known about the life history of the disease and there is little evidence to support the standard practice of surgery after resolution of the ®rst episode. Colonic perforation and abscesses are the commonest complications of an acute episode of diverticulitis.
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