Current Thinking

As has been seen, diverticular disease is common in the western world and can carry a significant morbidity. Although diverticular disease is common, it is still poorly understood and recent advances in the field continue to focus on the technological side (Cima and Young-Fadok, 2001). Improved computed tomography (CT) allows diagnosis and assessment to be made of severe acute diverticular disease and specialized teams using advanced endoscopic techniques are able to control diverticular bleeding, thereby removing the need for surgical intervention. As yet there are few randomized controlled trials to examine the evidence looking at this approach.

The Scientific Committee of the European Association for Endoscopic Surgery reported on their consensus development conference with the aim of resolving the current controversy over the diagnosis and treatment of diverticular disease (Kohler et al., 1999). A multidisciplinary team of international experts was convened to take part in the consensus exercise. Beforehand the panel was asked to reply to a series of questions on diverticular disease and the consensus statement from these questionnaires was modified at a joint meeting of the panel of experts. These were then presented at the public discussion and again revised by the convened panel of experts.

Using the Delphi method the final consensus was agreed with all the panel members. Asymptomatic diverticulosis, complicated diverticular disease and diverticular disease with actual or recurrent symptoms were all defined in separate categories. As an initial diagnostic tool there was no agreement about whether barium enema or colonoscopy was the better choice as a diagnostic tool in uncomplicated cases. CT is recommended in complicated cases for definitive diagnosis and, after two attacks of diverticular disease, elective surgical intervention should be considered. For those patients with complications, such as bleeding, stenosis and fistula, surgery is also indicated.

The mortality, morbidity and formation of a stoma appear to be dependent on whether the surgery is done by a specialist colorectal surgeon or a general surgeon. In addition the grade of surgeon operating can determine morbidity, mortality and stoma formation (Zorcolo et al., 2003). In the Edinburgh study it was concluded that primary anastomosis for diverticular disease can be performed with low morbidity and mortality in selected patients, thereby reducing the need for a Hartmann's procedure and colostomy, and the subsequent surgery for reversal and closure of the colostomy that can have high complication rates.

Faecal loading and faecal peritonitis do not preclude a primary anastomosis and the main factors contributing to favourable outcomes are the absence of concurrent disease and the patient's general health. Elderly patients who have a high American Society of Anesthesiologists (ASA) score were associated in this study with poorer outcomes.

Does diverticular disease affect the quality of life (QoL) of patients with long-standing symptoms? In a study by Bolster and Papagrigoriadis (2003) their literature search revealed that there were no QoL research studies into diverticular disease and that such studies would be of use in the selection of patients for elective surgical intervention. Structured interviews and questionnaires were given to 100 people, divided into two groups of 50. Group 1 had a diagnosis of diverticular disease with symptoms, and group 2 were well volunteers. The areas of QoL that were looked at were:

• emotional symptoms

• systemic symptoms

• bowel symptoms

• social function.

Scores in group 1 fell significantly behind those in group 2. Particular areas were bowel symptoms and emotional symptoms and all those in group 1 with diverticular disease scored significantly lower on all the QoL areas examined, compared with group 2. The authors believe that diverticular disease does affect a person's QoL and that further research is required so that a tool can be developed that would accurately measure the subjective health status of patients with diverticular disease; this would enable a systematic approach to the delivery of treatment and management of the patient with diverticular disease.

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Managing Diverticular Disease

Managing Diverticular Disease

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