Gender and Age in Diverticular Disease

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Although literature subscribes to the view that Littre, in 1732, was the first to mention diverticular disease, his description of 'diverticular hernia' was not explained. The first description is attributed to Sommering in his translation into German of Baillie's Morbid Anatomy in 1794 (Oschner and Bargen, 1935).

In 1968, Parks reported on the natural history of diverticular disease and found that women were more likely than men to be affected with up to 60% of patients being women. Since 1968, little work has been done to look at the difference in gender in diverticular disease. Other reported studies that have addressed selected complications of diverticular disease have made mention of gender, but there is no single study that is comprehensive and comes from an individual institution investigating all diverticular complications. In 2002, McConnell et al. presented a paper at the Tripartite Colorectal Meeting in Melbourne, Australia documenting their study of the population-based incidence of complicated diverticular disease of the sigmoid colon based on gender and age (McConnell et al., 2003). For a decade, between January 1988 and January 1998, a retrospective review was undertaken of all surgical patients admitted with proven diverticular disease that required surgery. Between January 1999 and December 1999 all patients who underwent flexible sigmoidoscopy were examined to determine the incidence of diverticular disease in the population. Patients were divided into categories of gender and age.

In the decade that was retrospectively examined for patients requiring surgical treatment, 934 were admitted to the department of Colorectal and General Surgery in the Mayo Clinic, Rochester, USA; 443 were male and 491 were female, with an average age of 64 years. Women appeared to present 5 years later than their male counterparts. In the flexible sigmoidoscopy group 10 037 operations were performed within the year period, with 5101 men and 4936 women of average age 57.58 years. Tables 10.1-10.3 show the complications and comparisons of age and gender.

Table 10.1 Comparisons of complications of diverticular disease (DD) between sexes

Complications

Male

Female

Total

Bleeding

34

15

49

Chronic/recurrent DD

148

181

329

Obstruction

25

36

61

Fistula

75

73

148

Perforation

82

88

170

Abscess

37

42

79

Stricture

21

38

59

Acute DD

21

18

39

Total

443

491

934

From McConnell et al. (2003).

From McConnell et al. (2003).

Table 10.2 Comparisons of complications of diverticular disease (DD) between age groups

Complications

< 50 years

> 50 years

Bleeding

2

47

Chronic/recurrent DD

64

265

Obstruction

4

57

Fistula

11

137

Perforation

20

150

Abscess

21

58

Stricture

3

56

Acute DD

8

31

Total

133

801

From McConnell et al. (2003).

From McConnell et al. (2003).

Table 10.3 Comparisons of complications of diverticular disease (DD) by age and sex

Complications

Men

Women

Men

Women

< 50 years

< 50 years

> 50 years

> 50 years

Bleeding

2

0

32

15

Chronic/recurrent DD

42

22

106

159

Obstruction

3

1

22

35

Fistula

10

1

65

72

Perforation

6

14

76

74

Abscess

9

12

28

30

Stricture

3

0

18

38

Acute DD

6

2

15

16

Total

81

52

362

439

From McConnell et al. (2003).

From McConnell et al. (2003).

Colonic diverticular disease is common in elderly people, with an increase in incidence as high as 30% in the eighth decade (McConnell et al., 2003) and up to 50% in the ninth decade (Biondo et al., 2002). The early studies show a male preponderance but recent studies still indicate a slight female preponderance, as Parks originally reported in 1968. In the Mayo Clinic review of complicated diverticular disease, males made up most patients aged below 40 years. Although diverticular bleeding that requires surgical intervention is considered to be a disease of elderly people, the population in the Mayo study found 31% of its patients to be younger than 70 years; of those 73% were male.

In looking at complications of diverticular disease, stricture of the sigmoid colon affects 5-25% of patients. Women older than 50 years were found to be twice as likely to develop a stricture that would require surgical intervention. Stricture of the sigmoid colon was found to be more common in the older patient with only 55 being younger than 50 years.

Obstruction of the colon complicating diverticular disease is rare with only a 10% incidence in all large bowel obstructions. Complete obstruction would occur when there is an acute abscess over a chronic stricture. Partial obstruction is more likely to occur when there is oedema and spasm or inflammatory changes. In the Mayo Clinic review no gender differences were reported in this area, with only 6.5% presenting before the age of 50 years and 63% older than 70 years.

The common complication of diverticular disease is diverticulitis, which may be acute or chronic. Nearly 80% of patients with acute diverticulitis recover sufficiently with medical treatment. Recurrent diverticulitis is thought to occur in as many as 7-35% of all patients irrespective of age and gender (Horgan et al., 2001). In patients aged under 40 years there are mixed reports of gender differences, notably with a preponderance of males (Reisman et al., 1999). In the Mayo Clinic study, of patients over 50 years, chronic diverticulitis presented in 111 men and 165 women.

Fistulae may complicate diverticular disease and are common; as many as 20% of patients may require surgery. In a study by Woods et al. (1988) it was found that, of 84 patients with colovesicular fistulae associated with diverticular disease, there was a 2:1 male preponderance. Women may be prevented from colovesicular fistula formation if they have a uterus. In the Mayo Study group 148 patients had colovesicular fistulae associated with diverticular disease and requiring surgery; 73 patients were female and 75 male. Of the female cohort 51% had previously undergone a hysterectomy; 7.4% of patients in this group were under the age of 50 years and only one was female.

The most worrying aspect of diverticular disease for surgeons is a colonic perforation. Although some perforation may wall off and create an abscess, peritonitis requires an emergency operation. Although there is not much in the literature to correlate age, gender and perforation in diverticular disease, one review reports an average of 44.7 years and another of 60 years (Tudor et al., 1994; Schwesinger et al., 2000). In McConnell et al.'s (2003) review, 170 patients of the cohort required surgical intervention as a result of perforation, with 11.7% of both sexes presenting before the age of 50 years. Women aged below 50 years were more commonly affected than men.

In Lee's (1986) survey in Singapore, 194 cases were found to have diverticular disease, which was evident in the large colon after the second decade; men were more frequently affected than women before the age of 60. Chinese men showed more diverticular disease than Malaysian and Indian men and Chinese men showed a significantly higher rate of diverticular disease than Chinese women. There was no significant difference between the prevalence of diverticular disease in Chinese and Indian women. In this survey there was far more right colon involvement (discussed in Chapter 9) with the disease affecting the caecum and ascending colon. In the three major ethnic groups in Singapore, this pattern was observed and occurred in both Singapore-born and foreign-born Singaporeans.

Diverticular disease starts to appear as early as the second decade in Singaporeans and in men the prevalence and rise were seen to be early and rapid, reaching a peak between the fifth and sixth decades, then rapidly dropping off. In women, the age prevalence of diverticular disease was low before the fifth decade, but rose sharply in the sixth decade, peaking in the eighth decade and showing only a small decline thereafter, compared with the sharp drop in later life experienced by men.

Although the relationship between physical activity and diverticular disease has not been directly studied, Aldoori et al. (1995) looked at a cohort of American men as a prospective study. They were aged between 40 and 75 years and diagnosed as free of diverticular disease before 1988. During the prospective study over 4 years, 382 new cases of symptomatic diverticular disease were recorded. Within the USA symptomatic diverticular disease accounts for 200 000 hospital admissions per year. Questionnaires based on self-report physical activity were given and the participants had to report on the average time per week spent at the identified activities, which were graded as moderate or vigorous. Dietary intake, as another variable, was used in a semi-quantitative questionnaire form. In follow-up questionnaires to the cohort every 2 years, participants were asked about diverticular disease during the previous 2 years. Response rates remained high and in 1992 were

94% at the time of analysis. The prospective data suggested that males who undertook physical activity and vigorous activity had a reduced risk of diverticular disease. Men who were more likely to have a higher risk of diverticular disease were those who took little physical activity and also had a dietary intake with low fibre.

As has been previously discussed, diverticulosis is common in elderly people, with the incidence reaching 50% in the ninth decade. The frequent reason for admission to hospital is the acute complication of diverticular disease. Among surgeons there is agreement that fistula, stenosis and haemorrhage in diverticular disease necessitate surgery, but there still is controversy about the treatment of young patients and their management of diverticulitis. It has been suggested that elective resection should be considered in young patients, i.e. under 50 years of age, when an acute infective episode is successfully managed conservatively, and that surgery should be considered because of the recurrent nature of diverticulitis and the possible complications (Konvolinka, 1994; Anderson et al., 1997). However, other authors report that, in patients aged under 40 years, diverticulitis does not have an aggressive nature (Ambrosetti et al., 1994; Spivak et al., 1997).

A study by Biondo et al. (2002) looked at the outcomes and management of diverticulitis in young patients and reported on the management, virulence and outcomes of acute diverticulitis with respect to age. In this study 22% of patients were first-time admissions under the age of 50 years. Ambrosetti et al. (1994) reported that patients younger than 50 years were more likely to have recurrences after conservative treatment, although older patients were more likely to require surgical intervention at first hospital admission. Biondo et al. (2002) found among his cohort that only 1 of 12 patients aged under 50 and 3 of 40 patients aged over 50 needed emergency surgery at the second attack of diverticulitis. However, in this study there was no specific evidence about the aggressive nature of diverticular disease in the young. The severity of peritonitis, as measured by the Hinchey classification, did not alter in either age group. Most patients in both age groups did not require surgery if their condition had responded to medical treatment after the first attack, leading the study's authors to believe that diverticular disease in young patients behaves no differently to the way it behaves in older patients and therefore that it should be managed with the same protocols.

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Responses

  • junior
    What ethnic group is prone to diverticulitis?
    9 months ago
  • longo
    Do men or women get diverticulitis the modt?
    8 months ago

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