Alimentary Pharmacology and Therapeutics
Letters to the Editors Letter: diverticulosis in inflammatory bowel diseases A. Tursi*, W. Elisei†, M. Picchio‡, G. Forti§, G. Giorgetti¶, R. Faggiani**, C. Zampaletta** & G. Brandimarte†† *Gastroenterology Service, ASL BAT, Andria, Italy. † Division of Gastroenterology, ASL Roma H, Albano Laziale, Italy. ‡ Division of Surgery, “P. Colombo” Hospital, Velletri, Italy. § Digestive Endoscopy Unit, “Santa Maria Goretti” Hospital, Latina, Italy. ¶ Digestive Endoscopy and Nutrition Unit, “S. Eugenio” Hospital, Rome, Italy. **Division of Gastroenterology, “Belcolle” Hospital, Viterbo, Italy. †† Division of Internal Medicine and Gastroenterology, “Cristo Re” Hospital, Rome, Italy. E-mail: [email protected] doi:10.1111/apt.12656
SIRS, Gisbert and Chaparro described in their systematic review the current management of inflammatory bowel
diseases in the elderly.1 Several factors affecting the correct diagnosis of inflammatory bowel disease (IBD) in elderly are identified, ranging from ischaemic colitis to diverticular disease.1 We know that real IBD rarely occurs in diverticulosis,2, 3 and that prevalence of diverticulosis among IBD patients (both in ulcerative colitis (UC) and in Crohn’s disease (CD) colitis) seems lower than among healthy, age-matched controls.4, 5 From January 2010 to December 2012, we performed a prospective study involving six Endoscopic Centres in central-south Italy. The study group included all patients with IBD (UC, CD and IBD undetermined). The control group included patients with no history of IBD. A total of 22 823 colonoscopies were performed during the observational period. Diverticulosis was diagnosed in 288 (12.3%) patients in the IBD group and in 2873 (19.4%) in the control group (P < 0.001).
Table 1 | Diverticulosis presence and extent according to the different inflammatory bowel disease types and location Left diverticulosis Ulcerative colitis Proctitis (112 pts) Distal colitis (203 pts) Left-sided colitis (719 pts) Pancolitis (298 pts) Total (1332 pts) Crohn’s disease Ileal (231 pts) Ileo-colonic (291 pts) Colonic (178 pts) Total (700 pts) Inflammatory bowel disease unclassified Ileal (31 pts) Ileo-colonic (114 pts) Colonic (183 pts) Total (328 pts)
Diffuse diverticulosis
Total
P*
51 35 25 15 126
(45.5) (17.3) (3.4) (5.0) (9.5)
18 11 12 6 47
(16.1) (5.4) (1.7) (2.1) (3.5)
69 46 37 21 173
(61.6) (22.7) (5.1) (7.1) (13.0)
0.000 NS NS NS
13 7 3 23
(5.6) (2.4) (1.7) (3.3)
6 3 1 10
(2.6) (1.0) (0.6) (1.4)
19 10 4 33
(8.2) (3.4) (2.3) (4.7)
0.007 NS NS
14 27 14 55
(45.2) (23.7) (7.7) (16.8)
5 19 3 27
(16.1) (16.7) (1.6) (8.2)
19 46 17 82
(61.3) (40.4) (9.3) (25.0)
0.000 NS NS
Data are expressed as numbers (percentage) of patients, unless otherwise specified. * Chi-square test. Values of P < 0.05 are considered as statistical difference; NS, not significant.
AP&T invited commentary and correspondence columns are restricted to letters discussing papers that have been published in the journal. A letter must have a maximum of 300 words, may contain one table or figure, and should have no more than 10 references. It should be submitted electronically to the Editors via http://mc.manuscriptcentral.com/apt.
ª 2014 John Wiley & Sons Ltd
899
Letters to the Editors Diverticulosis was more frequent with advancing age in the control group than in the IBD group. In particular, diverticulosis prevalence in the control group increased with age (from 10% in people ≤40 years to >45% in people ≥60 years), while it was stable in the IBD group starting from people ≤50 years to people ≥60 years (prevalence of 25–30%). Finally, diverticulosis occurred more frequently in IBD undetermined compared with UC and CD (P < 0.001). With respect to IBD location, diverticulosis was more frequent when rectum and/or ileum were involved (Table 1). As diverticulosis is believed to be generated by elevated intracolonic pressure, a possible explanation of the low diverticulosis prevalence in UC may be that chronic inflammation and its chemical mediators cause muscular relaxation with lower intraluminal pressures.6, 7 We also know that hard stool may increase intracolonic pressure: a combination of relatively loose stools, leading to low intracolonic pressure, and a thicker bowel wall, as a consequence of the prolonged inflammation, may make the colonic wall more resistant to intraluminal pressures in CD patients, explaining why diverticulosis prevalence in CD is the lowest among IBD patients. With respect to the higher prevalence of diverticulosis in IBD undetermined, we hypothesise that IBD undetermined may be considered as similar to early UC,8, 9 in which chronic inflammation is limited to the mucosal layer. Consequently, these patients may have a thin muscular wall that is more sensitive to higher intracolonic pressure. Although the exact mechanism responsible for these observations is yet to be assessed, the role of chronic inflammation in determining lower diverticulosis
Letter: a physiological dose of lactose and fructose is necessary to demonstrate intolerance P. Usai-Satta Gastroenterology Unit, Brotzu Hospital, Cagliari, Italy. E-mail: [email protected] doi:10.1111/apt.12677
SIRS, Wilder-Smith et al.1 reported that lactose and fructose intolerances are common in patients with functional gastrointestinal disorders. On the other hand, these intol900
prevalence in IBD patients than in the general population seems to be reasonable.
ACKNOWLEDGEMENT Declaration of personal and funding interests: None. REFERENCES 1. Gisbert JP, Chaparro M. Systematic review with meta-analysis: inflammatory bowel disease in the elderly. Aliment Pharmacol Ther 2014; 39: 459–77. 2. Tursi A, Elisei W, Giorgetti GM, Aiello F, Brandimarte G. Inflammatory manifestations at colonoscopy in patients with colonic diverticular disease. Aliment Pharmacol Ther 2011; 33: 358–65. 3. Tursi A, Elisei W, Picchio M. Incidence and prevalence of inflammatory bowel diseases in gastroenterology primary care setting. Eur J Intern Med 2013; 24: 852–6. 4. Rispo A, Pasquale L, Cozzolino A, et al. Lower prevalence of diverticulosis in patients with ulcerative colitis. Dis Colon Rectum 2007; 50: 1164–8. 5. Lahat A, Avidan B, Bar-Meir S, Chowers Y. Long-standing colonic incflammation is associated with a low prevalence of diverticuli in inflammatory bowel disease patients. Inflamm Bowel Dis 2007; 13: 733–6. 6. Cao W, Vrees MD, Potenti MF, Harnett KM, Fiocchi C, Pricolo VE. Interleukin 1beta-induced production of H2O2 contributes to reduced sigmoid colonic circular smooth muscle contractility in ulcerative colitis. J Pharmacol Exp Ther 2004; 311: 60–70. 7. Cao W, Fiocchi C, Pricolo VE. Production of IL-1beta, hydrogen peroxide and nitric oxide by colon mucosa decreases sigmoid smooth muscle contractility in ulcerative colitis. Am J Physiol Cell Physiol 2005; 289: 1408–16. 8. Kleer CG, Appelman HD. Ulcerative colitis – patterns of involvement in colorectal biopsies and changes with time. Am J Surg Pathol 1998; 22: 983–9. 9. Kim B, Barnett JL, Kleer CG, Appelman HD. Endoscopic and histological patchiness in treated ulcerative colitis. Am J Gastroenterol 1999; 94: 3258–62.
erances were often present in the absence of sugar malabsorption. To perform a hydrogen breath testing (HBT), the authors proposed a procedure based on an unpublished pilot study: breath samples were collected hourly for 5 h, after 50 g of lactose and 35 g of fructose. The authors admitted to having used doses higher than usually ingested during a meal, but they considered this dosage as a provocation test to identify patients likely to benefit from dietary manipulation even in the absence of malabsorption. In 2007, the Rome consensus conference was convened to offer recommendations for clinical practice about HBT and an article was published in 2009.2 In
Aliment Pharmacol Ther 2014; 39: 899-903 ª 2014 John Wiley & Sons Ltd
Letters to the Editors Letter: diverticulosis in inflammatory bowel diseases A. Tursi*, W. Elisei†, M. Picchio‡, G. Forti§, G. Giorgetti¶, R. Faggiani**, C. Zampaletta** & G. Brandimarte†† *Gastroenterology Service, ASL BAT, Andria, Italy. † Division of Gastroenterology, ASL Roma H, Albano Laziale, Italy. ‡ Division of Surgery, “P. Colombo” Hospital, Velletri, Italy. § Digestive Endoscopy Unit, “Santa Maria Goretti” Hospital, Latina, Italy. ¶ Digestive Endoscopy and Nutrition Unit, “S. Eugenio” Hospital, Rome, Italy. **Division of Gastroenterology, “Belcolle” Hospital, Viterbo, Italy. †† Division of Internal Medicine and Gastroenterology, “Cristo Re” Hospital, Rome, Italy. E-mail: [email protected] doi:10.1111/apt.12656
SIRS, Gisbert and Chaparro described in their systematic review the current management of inflammatory bowel
diseases in the elderly.1 Several factors affecting the correct diagnosis of inflammatory bowel disease (IBD) in elderly are identified, ranging from ischaemic colitis to diverticular disease.1 We know that real IBD rarely occurs in diverticulosis,2, 3 and that prevalence of diverticulosis among IBD patients (both in ulcerative colitis (UC) and in Crohn’s disease (CD) colitis) seems lower than among healthy, age-matched controls.4, 5 From January 2010 to December 2012, we performed a prospective study involving six Endoscopic Centres in central-south Italy. The study group included all patients with IBD (UC, CD and IBD undetermined). The control group included patients with no history of IBD. A total of 22 823 colonoscopies were performed during the observational period. Diverticulosis was diagnosed in 288 (12.3%) patients in the IBD group and in 2873 (19.4%) in the control group (P < 0.001).
Table 1 | Diverticulosis presence and extent according to the different inflammatory bowel disease types and location Left diverticulosis Ulcerative colitis Proctitis (112 pts) Distal colitis (203 pts) Left-sided colitis (719 pts) Pancolitis (298 pts) Total (1332 pts) Crohn’s disease Ileal (231 pts) Ileo-colonic (291 pts) Colonic (178 pts) Total (700 pts) Inflammatory bowel disease unclassified Ileal (31 pts) Ileo-colonic (114 pts) Colonic (183 pts) Total (328 pts)
Diffuse diverticulosis
Total
P*
51 35 25 15 126
(45.5) (17.3) (3.4) (5.0) (9.5)
18 11 12 6 47
(16.1) (5.4) (1.7) (2.1) (3.5)
69 46 37 21 173
(61.6) (22.7) (5.1) (7.1) (13.0)
0.000 NS NS NS
13 7 3 23
(5.6) (2.4) (1.7) (3.3)
6 3 1 10
(2.6) (1.0) (0.6) (1.4)
19 10 4 33
(8.2) (3.4) (2.3) (4.7)
0.007 NS NS
14 27 14 55
(45.2) (23.7) (7.7) (16.8)
5 19 3 27
(16.1) (16.7) (1.6) (8.2)
19 46 17 82
(61.3) (40.4) (9.3) (25.0)
0.000 NS NS
Data are expressed as numbers (percentage) of patients, unless otherwise specified. * Chi-square test. Values of P < 0.05 are considered as statistical difference; NS, not significant.
AP&T invited commentary and correspondence columns are restricted to letters discussing papers that have been published in the journal. A letter must have a maximum of 300 words, may contain one table or figure, and should have no more than 10 references. It should be submitted electronically to the Editors via http://mc.manuscriptcentral.com/apt.
ª 2014 John Wiley & Sons Ltd
899
Letters to the Editors Diverticulosis was more frequent with advancing age in the control group than in the IBD group. In particular, diverticulosis prevalence in the control group increased with age (from 10% in people ≤40 years to >45% in people ≥60 years), while it was stable in the IBD group starting from people ≤50 years to people ≥60 years (prevalence of 25–30%). Finally, diverticulosis occurred more frequently in IBD undetermined compared with UC and CD (P < 0.001). With respect to IBD location, diverticulosis was more frequent when rectum and/or ileum were involved (Table 1). As diverticulosis is believed to be generated by elevated intracolonic pressure, a possible explanation of the low diverticulosis prevalence in UC may be that chronic inflammation and its chemical mediators cause muscular relaxation with lower intraluminal pressures.6, 7 We also know that hard stool may increase intracolonic pressure: a combination of relatively loose stools, leading to low intracolonic pressure, and a thicker bowel wall, as a consequence of the prolonged inflammation, may make the colonic wall more resistant to intraluminal pressures in CD patients, explaining why diverticulosis prevalence in CD is the lowest among IBD patients. With respect to the higher prevalence of diverticulosis in IBD undetermined, we hypothesise that IBD undetermined may be considered as similar to early UC,8, 9 in which chronic inflammation is limited to the mucosal layer. Consequently, these patients may have a thin muscular wall that is more sensitive to higher intracolonic pressure. Although the exact mechanism responsible for these observations is yet to be assessed, the role of chronic inflammation in determining lower diverticulosis
Letter: a physiological dose of lactose and fructose is necessary to demonstrate intolerance P. Usai-Satta Gastroenterology Unit, Brotzu Hospital, Cagliari, Italy. E-mail: [email protected] doi:10.1111/apt.12677
SIRS, Wilder-Smith et al.1 reported that lactose and fructose intolerances are common in patients with functional gastrointestinal disorders. On the other hand, these intol900
prevalence in IBD patients than in the general population seems to be reasonable.
ACKNOWLEDGEMENT Declaration of personal and funding interests: None. REFERENCES 1. Gisbert JP, Chaparro M. Systematic review with meta-analysis: inflammatory bowel disease in the elderly. Aliment Pharmacol Ther 2014; 39: 459–77. 2. Tursi A, Elisei W, Giorgetti GM, Aiello F, Brandimarte G. Inflammatory manifestations at colonoscopy in patients with colonic diverticular disease. Aliment Pharmacol Ther 2011; 33: 358–65. 3. Tursi A, Elisei W, Picchio M. Incidence and prevalence of inflammatory bowel diseases in gastroenterology primary care setting. Eur J Intern Med 2013; 24: 852–6. 4. Rispo A, Pasquale L, Cozzolino A, et al. Lower prevalence of diverticulosis in patients with ulcerative colitis. Dis Colon Rectum 2007; 50: 1164–8. 5. Lahat A, Avidan B, Bar-Meir S, Chowers Y. Long-standing colonic incflammation is associated with a low prevalence of diverticuli in inflammatory bowel disease patients. Inflamm Bowel Dis 2007; 13: 733–6. 6. Cao W, Vrees MD, Potenti MF, Harnett KM, Fiocchi C, Pricolo VE. Interleukin 1beta-induced production of H2O2 contributes to reduced sigmoid colonic circular smooth muscle contractility in ulcerative colitis. J Pharmacol Exp Ther 2004; 311: 60–70. 7. Cao W, Fiocchi C, Pricolo VE. Production of IL-1beta, hydrogen peroxide and nitric oxide by colon mucosa decreases sigmoid smooth muscle contractility in ulcerative colitis. Am J Physiol Cell Physiol 2005; 289: 1408–16. 8. Kleer CG, Appelman HD. Ulcerative colitis – patterns of involvement in colorectal biopsies and changes with time. Am J Surg Pathol 1998; 22: 983–9. 9. Kim B, Barnett JL, Kleer CG, Appelman HD. Endoscopic and histological patchiness in treated ulcerative colitis. Am J Gastroenterol 1999; 94: 3258–62.
erances were often present in the absence of sugar malabsorption. To perform a hydrogen breath testing (HBT), the authors proposed a procedure based on an unpublished pilot study: breath samples were collected hourly for 5 h, after 50 g of lactose and 35 g of fructose. The authors admitted to having used doses higher than usually ingested during a meal, but they considered this dosage as a provocation test to identify patients likely to benefit from dietary manipulation even in the absence of malabsorption. In 2007, the Rome consensus conference was convened to offer recommendations for clinical practice about HBT and an article was published in 2009.2 In
Aliment Pharmacol Ther 2014; 39: 899-903 ª 2014 John Wiley & Sons Ltd
