Clinical spectrum of colonic diverticulosis: a tertiary care experience in Saudi Arabia - IJMDC
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Abed AlLehbi et al, 2021;5(2):423–427. International Journal of Medicine in Developing Countries https://doi.org/10.24911/IJMDC.51-1594026501 ORIGINAL ARTICLE Clinical spectrum of colonic diverticulosis: a tertiary care experience in Saudi Arabia Abed AlLehbi1, Ibrahim Masoodi2*, Abdullah AlMtawa1, Adel Alqutub1, Khalid Alsayari1, Ahmed O. Alomair1 ABSTRACT Background: The prevalence of colonic diverticulosis has increased in recent years in Saudi Arabia (SA). Thereby, this study aimed at exploring the clinical pattern, characteristics, and association of colonic diverticulosis in SA. Methodology: This was a cross-sectional observational study conducted on 2,134 colonoscopic procedures carried out at King Fahad Medical City, a tertiary care center in Riyadh, SA, from October 2014 to July 2018. The data on 217 patients with colonic diverticulosis were randomly selected for analysis. Results: Of the 217 patients with diverticulosis, 52% were male. The mean age was 63.04 ± 12.8 years. Entire colon diverticulosis was found in 15.4% of the study population, while 32.7% had sigmoid diverticulosis. Around 11% of the participants presented with abdominal pain, constipation in 6%, and anemia in 11.1%, positive occult blood in 2.8%, and lower Gastrointestinal (GI) bleeding in 5.5%. Regarding diagnostic procedures, computerized tomography was used for 4.6% of the participants, while barium enema was used for 0.5% of the participants. Regarding comorbidity, hypertensive patients constituted 55.8% of the participants, 46.1% were diabetic, 18.9% had ischemic heart diseases (IHDs), while end-stage renal disease was reported in 2.8% of the study cohort. Conclusion: Diverticulosis is common in both genders and in the younger age group as well. The association of diverticular disease with diabetes, IHD, and hypertension was similar to other regions of the globe. Keywords: Colonic diverticulosis, colonoscopy, gastrointestinal disorders, SA. Introduction Diverticulosis is considered as a common benign disease age group and predominantly among males [5,6]. Another of the colon. Although it is an asymptomatic disease, its retrospective study conducted in SA reviewed patients complications and impact on health services are well who underwent colonoscopy with different etiologies known. In one study it was observed that diverticulitis between 2007 and 2011 and found diverticulosis in 7.4% or diverticulosis caused 2,682,168 outpatient visits of the participants [6]. and 283,355 hospitalization discharges in 2009 [1]. While previously it was believed that diverticulosis and The prevalence of the diverticular disease is apparently diverticulitis are both common in populations older than predominant in the United States of America and western 80 years, nowadays many studies have revealed that countries [2]. Nevertheless, there is a worldwide health diverticulosis might affect people younger than 40 years concern regarding the diagnosis and management of old as well [7,8]. Although an unclear role of gender on diverticulosis and the disease is no longer uncommon in prevalence of the diseases still exists, previous studies other parts of the globe. While the etiopathogenesis of have found a rise in male gender over females [6,7,9]. diverticulosis remains elusive, it is believed that a low Few studies involved the link between diverticulosis and fiber diet, non-absorbable antibiotics, probiotics, and 5-aminosalicylic acid could reveal the symptoms [1,3]. An earlier study revealed that the disease started to peak in the Correspondence to: Ibrahim Masoodi 20th century and autopsy studies unraveled diverticulitis *Department of Medical Gastroenterology, Yenepoya and diverticulosis in corpses of the 19th century, all in Medical College, Mangalore, India. the older age group. The study also linked the geographic Email: Ibrahimmasoodi@yahoo.co.in factors leading to the worsening of symptoms or even Full list of author information is available at the end of affecting specific population [4]. Previous studies across the article. Israel, Jordan, and Saudi Arabia (SA) have concluded that Received: 06 July 2020 | Accepted: 20 December 2020 diverticulosis peaked in the last few years among the older © IJMDC. https://www.ijmdc.com 423
Spectrum of colonic diverticulosis
provoked chronic diseases. One study revealed a positive The data regarding association of Diverticulosis with
correlation of high systolic blood pressure, decreased systemic disease revealed the presence of DM in 36.1%
low density lipoproteins, high cholesterol level, and of the patients, hypertension in 55.8%, end-stage renal
diverticulosis disease; however, the above-mentioned disease (ESRD) in 2.8%, and ischemic heart disease (IHD)
study could not reveal any association between physical in 18.9% of the participants. Around 2.8% had positive
activity, smoking, or alcohol with the disease [9]. occult blood and were found to have diverticulosis on
Diverticulosis is often an asymptomatic disease [1,5]. The colonoscopic examination. The diagnostic procedures
disease is mostly diagnosed by computerized tomography used for detection of diverticulosis were CT scan in 4.6%
(CT) scan or X–ray, revealing 25% of symptomatic and barium enema in 0.5%. All patients underwent a
cases. Most of the diverticulosis occurs in the sigmoid standard colonoscopic examination and the diverticular
colon [10]. Patients might suffer from abdominal pain disease was confirmed.
either isolated or recurrent, constipation, or diarrhea, and The symptoms and association of various chronic
in complicated cases, anemia or rectal bleeding [6,10]. diseases were also recorded. Diabetic patients comprised
Azzam et al. [6] revealed that diverticulosis was the 46.1% of the cases and hypertensive cases were 55.8% of
second most common cause of lower gastrointestinal the cases; ESRD was found in 2.8% and IHD in 18.9% of
bleeding in 33.6% of the cases, and adenomatous polyps, the cases (Table 1).
hypertension, and diabetes mellitus (DM) all have a
The sites of diverticulosis were reported as follows:
positive correlation with diverticulosis.
sigmoid DVS (Diverticulosis) (32.7%), left /sigmoid
Keeping in view the changing trends in colonic (18.9%), entire colon (15.7%), left-sided (12.9%), right-
diverticulosis across the globe, this study was conducted sided (7.8%), transverse (6.5%), and recto sigmoid DVS
to get an insight in the clinical spectrum of diverticulosis (Diverticulosis) (5.5%).
in SA.
Subjects and Methods
This cross-sectional observational study was conducted Table 1. Clinical characteristics of the study cohort (n = 217).
at King Fahad Medical City, a tertiary care center in Clinical characteristics Frequency and %
Riyadh, SA, from October 2014 to July 2018. Of 2,134
Mean age 63.04 ± 12.80 years
colonoscopic procedures carried out in the Department
of Gastroenterology, only 217 patients were found to Range 31-99 years
have colonic diverticulosis and their data were randomly Gender 52% males
selected for the analysis. Adult patients underwent Clinical symptoms
colonoscopic examination for various GI ailments like Pain abdomen 24 (11%)
anemia, constipation, and lower GI bleed with adequate
Constipation 13 (6%)
bowel preparation after an informed consent. Standard
bowel preparation was used before the colonoscopy Symptomatic anemia 24 (11%)
procedure. However, patients with inadequate bowel Lower GI bleeding 12 (5.5%)
preparation and patients with symptomatic diverticular Screening colonoscopy 6 (2.7%)
disease were excluded. Co morbidities
Data were statistically described in terms of frequencies DM 100 (46.1%)
(number of cases), median, and valid percentages Hypertension 121 (55.8%)
for categorical variables. Pearson’s chi-square (two-
ESRD 6 (2.8%)
sided) was used to determine the correlation between
non-parametric variables. All statistical calculations IHD 41 (18.9%)
were carried out using Statistical Package for Social Site of diverticulosis
ScienceStatistical Package for the Social Science Right side 17 (7.8%)
computer program 21.0IBM SPSS. Entire colon 34 (15.7%)
Results Transverse colon 14 (6.5%)
Left side 28 (12.9%)
Of the 2,134 colonoscopic procedures the data of 217 Sigmoid colon 71 (32.7%)
patients with confirmed diverticulosis were analyzed.
Left side colon + sigmoid colon 41 (18.9%)
There were 52% of males and 48% of females. The
patient’s age was 63.04 ± 12.8 years and their age Recto sigmoid 12 (5.5%)
ranged from 31 to 99 years. Of the 217 patients, 11% Diagnostic tool used
had abdominal pain and diverticulosis was detected on CT SCAN 10 (4.6%)
colonoscopic examination. Around 6% of the patients Barium enema 1 (0.5%)
had presented with constipation and were found to have
Colonoscopy 217 (100%)
diverticulosis, while 11.1% of the patients with anemia
had diverticulosis on colonoscopic examination. IHD = Ischemic heart disease; ESRD = End-stage renal disease.
424Spectrum of colonic diverticulosis
The site of diverticulosis in relation to various chronic cancer, thus colonoscopy is recommended for further
illnesses was also assessed. In DM patients, the most differentiation of the disease by various researchers
predominant site of diverticulosis was in the sigmoid [11,14,15].
region (26 cases), followed by left-sided/sigmoid (25
Colonic diverticulosis is usually asymptomatic but when
cases),and entire colon (17 cases). However, Pearson’s
the symptoms (pain, fever, and hemorrhage) appear,
chi-squared test was calculated and it was not significant.
it affects the patient’s life; therefore, it is important to
However, in ESRD, entire colon cases accounted for two
assess the severity and set management goals ranging
cases as well as in left/sigmoid colon while left-sided
from conservative management to surgery [3,15].
and transverse colon were one case each. Pearson’s chi-
squared test was insignificant. Furthermore, left-sided/ Previously, dietary fiber was thought to have a direct
sigmoid DVS (Diverticulosis) predominated in IHDs contribution to the formation of diverticulosis and the
with 14 cases, followed by entire colon with 10 cases, western diet, and low fiber has long been implicated
sigmoid cases alone with eight cases, three were left– in the development of diverticulosis [16-18]. However,
sided, and no case was recorded in transverse colon. recent data have questioned the role of fiber in the
Pearson’s chi-squared test was insignificant. development of diverticulosis especially if genetic,
environmental, cultural, dietary, or other variables are
Discussion taken into consideration, leaving a big dilemma on
whether changing the diet could help relieve pain or
While diverticulosis and its complications are common in decline its recurrence in a given clinical situation [19,20].
the west, diverticulosis is no more uncommon in the Middle
East countries, including SA. Its prevalence is largely The current study revealed that 2.8% of the patients
age-dependent; however, in recent years, the disease has with positive occult blood proved to have diverticulosis
become popular among the age group younger than 40 on colonoscopic examination. Thereby, it is prudent to
years as well. The diverticulosis was observed in patients evaluate occult blood, especially in patients with alarming
below the age of 40 in this study, which needs further symptoms with pan endoscopy to arrive at a diagnosis.
study. The colonic diverticulosis was frequent among However, there are limited cases where diverticulosis is
males, nevertheless female patients older than 50 years of recorded to be the cause of occult blood in stools [21].
age were affected by the disease as well [7]. The current Coronary artery disease was found to be associated with
study showed that 52% of the participants were men and diverticulosis in this study. In a retrospective national
the mean age of the participants was 63 ± 12.79 years. study from Taiwan, it was observed that the overall
Complications of diverticulosis in males were lesser incidence of acute coronary syndrome in patients with
compared to females. In a study, the gender difference, diverticular disease were 45.5/10,000 person in 1 year
between 1998 and 2005, and the hospitalization rates and was significantly higher than in those without
of women were nearly double compared to men. This diverticular disease (30.3/10,000 person in 1 year) [22].
difference is postulated to be due to the protective effects In another study, the incidence of diverticulosis in IHD
of testosterone on the male gut wall compared to females patients were 57% higher than among male control
where pregnancy and hormonal effects predispose them subjects (25%) from the same age and social category
to complications of the disease [2]. [23].
The results of the current study revealed that the Another association observed in this study was
commonest site of diverticulosis was in the sigmoid colon that of diverticulosis with hypertension, which was
and left end of the sigmoid colon. Diverticulosis was found by other studies as well [23,24]. Moreover,
noted in 18.9% of the study participants, and this is in line antihypertensive drugs were detected in many cases to
with other studies [6,7]. The above-mentioned studies contribute to the hemorrhage in diverticulosis [24,25].
have demonstrated a high incidence of diverticulosis in While complications of diverticulosis in ESRD in the
the sigmoid colon in both western population and Middle form of perforation and abscesses have been described
East population as was observed in the current study. On in the literature, the current results showed a positive
the contrary, most Asians studies have observed right- association between ESRD and diverticulosis, but it did
sided diverticulosis ranging from 8% to 22% [11,12]. not reach significant levels, possibly due to the small
This study revealed right-sided diverticulosis in 7.8% number of ESRD patients in the study cohort [26].
of the participants. While transverse sigmoid colon The association between diabetes and diverticulosis is
diverticulosis is considered to be rare in the literature well described in the literature. In 2017, a meta-analysis
[13], transverse diverticulosis represented 6.5% of the revealed that there is a direct correlation between DM
study cohort. and colonic diverticular disease (CDD) and colonic
Two diagnostic procedures (CT scan abdomen and barium diverticular hemorrhage (CDH). Patients with DM were
enema) were involved for the diagnosis of diverticulosis 1.21 times at a higher risk of developing CDD and had
in this study and diverticulosis was confirmed by increased CDH by 52.8% [27]. The current study showed
standard colonoscopy in all patients. The role of CT scan that patients with DM had a higher sigmoid diverticulosis
abdomen in diverticulosis is well established, although (26 cases), entire colon diverticulosis in (17 cases), and
diverticulosis might get misdiagnosed with colon recto sigmoid (six cases).
425Spectrum of colonic diverticulosis
The limitation of this study was that the current study was 5. Levy N, Luboshitzki R, Shiratzki Y Ghivarello M.
hospital-based and not population-based. Furthermore, Diverticulosis of the colon in Israel. Dis Colon Rectum.
the dietary factors with diverticulosis were not explored 1977;20:477. https://doi.org/10.1007/BF02586584
in the study cohort. 6. Azzam N, Aljebreen AM, Alharbi O, Almadi MA.
Prevalence and clinical features of colonic diverticulosis
Conclusion in a Middle Eastern population. World J Gastrointest
Endosc. 2013;5(8):391–7. https://doi.org/10.4253/wjge.
Based on the discussed results it is concluded that v5.i8.391
diverticulosis is common in both genders and present in 7. Weizman AV, Nguyen GC. Diverticular disease:
the younger age group as well, which needs further study. epidemiology and management. Can J Gastroenterol.
The association of diverticular disease with diabetes, 2011;25(7):385–9. https://doi.org/10.1155/2011/795241
IHD, and hypertension in this part of the globe is similar
8. Schauer PR, Ramos R, Ghiatas AA, Sirinek KR. Virulent
to other regions of the world. diverticular disease in young obese men. Am J Surg.
List of Abbreviations 1992;164(5):443–8. https://doi.org/10.1016/S0002-9610
(05)81177-8
CDD Colonic Diverticular Disease
CDH Colonic Diverticular Hemorrhage 9. Yamamichi N, Shimamoto T, Takahashi Y, Sakaguchi
CT Computerized tomography Y, Kakimoto H, Matsuda R, et al. Trend and risk factors
DM Diabetes Mellitus of diverticulosis in Japan: age, gender, and lifestyle/
metabolic-related factors may cooperatively affect
ESRD End-stage renal disease
on the colorectal diverticula formation. PLoS One.
IHD Ischemic heart disease
2015;10(4):e0123688. https://doi.org/10.1371/journal.
SA Saudi Arabia pone.0123688
Conflict of interest 10. Špičák J, Kučera M, Suchánková G. Diverticular disease:
The authors declare that there is no conflict of interest diagnosis and treatment. Vnitr̆ Lék. 2018;64(6):621–34.
regarding the publication of this article. 11. Munakata A, Nakaji S, Takami H, Nakajima H, Iwane
S, Tuchida S. Epidemiological evaluation of colonic
Funding diverticulosis and dietary fiber in Japan. Tohoku J Exp
None. Med. 1993;171:145–51. https://doi.org/10.1620/tjem.
171.145
Consent to participate
Written informed consent was obtained from all the 12. Chan CC, Lo KK, Chung EC, Lo SS, Hon TY. Colonic
diverticulosis in Hong Kong: distribution pattern and
participants.
clinical significance. Clin Radiol. 1998;53:842–4. https://
Ethical approval doi.org/10.1016/S0009-9260(98)80197-9
The study was approved by the ethical committee and was 13. Solak A, Solak I, Genç B, Sahin N, Yalaz S. Transverse
conducted according to the research guidelines of King Fahad colon diverticulitis with calcified fecalith. Eurasian J
Medical City, Riyadh, Saudi Arabia. IRB Registration number Med. 2013;45(1):68–70. https://doi.org/10.5152/eajm.
with KFMC,KSA CDD-02-T-,069 approval number 230). 2013.14
14. Salzman H, Lillie D. Diverticular disease: diagnosis and
Author details treatment. Am J Fam Physician. 2005;72(7):1229–34.
Abed AlLehbi1, Ibrahim Masoodi2 , Abdullah AlMtawa1, Adel 15. Diagnosis of Diverticular Disease. National Institute
Alqutub1, Khalid Alsayari1, Ahmed O. Alomair1 of Diabetes and Digestive and Kidney Diseases. [cited
1. Department of Gastroenterology, King Fahad Medical City, 2018 Dec]. Available from: https://www.niddk.nih.gov/
Riyadh, Saudi Arabia health-information/digestive-diseases/diverticulosis-
2. Department of Medical Gastroenterology, Yenepoya diverticulitis/diagnosis
Medical College, Mangalore, India 16. Diverticulosis and Diverticulitis. American College of
References Gastroenterology. [cited 2018 Dec]. Available from: http://
patients.gi.org/topics/diverticulosis-and-diverticulitis/
1. Feuerstein JD, Falchuk KR. Diverticulosis and diverticulitis.
17. Aldoori WH, Giovannucci EL, Rimm EB, Wing AL,
Mayo Clin Proc. 2016;91(8):1094–104. https://doi.org/10.
Trichopoulos DV, Willett WC. A prospective study of
1016/j.mayocp.2016.03.012
diet and the risk of symptomatic diverticular disease in
2. Etzioni DA, Mack TM, Beart Jr RW, Kaiser AM. Diverticulitis men. Am J Clin Nutr. 1994;60(5):757–64. https://doi.
in the United States: 1998-2005: changing patterns of org/10.1093/ajcn/60.5.757
disease and treatment. Ann Surg. 2009;249(2):210–7.
18. Burkitt DP, Walker AR, Painter NS. Effect of dietary
https://doi.org/10.1097/SLA.0b013e3181952888
fiber on stool and the transit-times, and its role in the
3. Elisei W, Brandimarte G, Tursi A. Management of causation of disease. Lancet. 1972;2:1408–12. https://
diverticulosis: what's new? Minerva Med. 2017;108(5): doi.org/10.1016/S0140-6736(72)92974-1
448–63.
19. Talbot JM. Role of dietary fiber in diverticular disease and
4. Painter NS, Burkitt DP. Diverticular disease of the colon cancer. Fed Proc. 1981;40(9):2337–42.
colon: a deficiency disease of Western civilization. Br
20. Carabotti M, Annibale B, Severi C, Lahner E. Role of fiber
Med J. 1971;2(5759):450–4. https://doi.org/10.1136/
in symptomatic uncomplicated diverticular disease: a
bmj.2.5759.450
426Spectrum of colonic diverticulosis
systematic review. Nutrients. 2017;9(2):161. https://doi. colonic diverticular hemorrhage. Dis Colon Rectum.
org/10.3390/nu9020161 2008;51:116–20. https://doi.org/10.1007/s10350-007-
21. De Minicis S, Antonini F, Belfiori V, De Minicis S, 9137-8
Antonini F, Belfiori V, et al. Small bowel diverticulitis 25. Jansen A, Harenberg S, Grenda U, Elsing C. Risk factors
with severe anemia and abdominal pain. World J Clin for colonic diverticular bleeding: a Westernized
Cases. 2015;3(5):462–5. https://doi.org/10.12998/wjcc. community based hospital study. World J Gastroenterol.
v3.i5.462 2009;15(4):457–61. https://doi.org/10.3748/wjg.15.457
22. Lin JN, Lin CL, Yang CH, Lin MC, Lai CH, Lin HH, et al. 26. Dirweesh A, Amodu A, Khan M, Zijoo R, Ambreen B,
Increased risk of acute coronary syndrome in patients Ibrahim M, et al. Symptomatic diverticular disease in
with diverticular disease: a nationwide population-based patients with severely reduced kidney function: higher
study. Medicine (Baltimore). 2015;94(45):e2020. https:// rates of complications and transfusion requirement.
doi.org/10.1097/MD.0000000000002020 Gastroenterol Res. 2017;10(1):15. https://doi.org/10.14
23. Foster KJ, Holdstock G, Whorwell PJ, Guyer P, Wright R. 740/gr784w
Prevalence of diverticular disease of the colon in patients 27. Lin X, Li J, Ying M, Wei F, Xie X. Diabetes increases
with ischemic heart disease. Gut. 1978;19(11):1054–6. morbidities of colonic diverticular disease and colonic
https://doi.org/10.1136/gut.19.11.1054 diverticular hemorrhage: a systematic review and meta-
24. Yamada A, Sugimoto T, Kondo S, Ohta M, Watabe analysis. Am J Ther. 2017;24(2):e213–21. https://doi.
H, Maeda S, et al. Assessment of the risk factors for org/10.1097/MJT.0000000000000410
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