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. 2002 Nov;78(925):654–658. doi: 10.1136/pmj.78.925.654

Epidemiology of perforated colonic diverticular disease

C Morris 1, I Harvey 1, W Stebbings 1, C Speakman 1, H Kennedy 1, A Hart 1
PMCID: PMC1742564  PMID: 12496319

Abstract

Perforated colonic diverticular disease results in considerable mortality and morbidity. This review appraises existing evidence on the epidemiology and mechanisms of perforation, highlights areas of further study, and suggests an epidemiological approach towards preventing the condition. Computerised searches were used to identify published articles relating to the epidemiology, pathophysiology, and clinical features of perforated colonic diverticular disease. Several drug and dietary exposures have potential biological mechanisms for causing perforation. Of these only non-steroidal anti-inflammatory drugs have been consistently identified as risk factors in aetiological studies. The causes of perforated colonic diverticular disease remain largely unknown. Further aetiological studies, looking specifically at perforation, are required to investigate whether cause-effect relationships exist for both drug and dietary exposures. The identification of risk factors for perforation would allow primary public health prevention, secondary risk factor modification, and early prophylactic surgery to be aimed at people at high risk.

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Selected References

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  1. Aldoori W. H., Giovannucci E. L., Rimm E. B., Wing A. L., Trichopoulos D. V., Willett W. C. A prospective study of alcohol, smoking, caffeine, and the risk of symptomatic diverticular disease in men. Ann Epidemiol. 1995 May;5(3):221–228. doi: 10.1016/1047-2797(94)00109-7. [DOI] [PubMed] [Google Scholar]
  2. Aldoori W. H., Giovannucci E. L., Rimm E. B., Wing A. L., Trichopoulos D. V., Willett W. C. A prospective study of diet and the risk of symptomatic diverticular disease in men. Am J Clin Nutr. 1994 Nov;60(5):757–764. doi: 10.1093/ajcn/60.5.757. [DOI] [PubMed] [Google Scholar]
  3. Aldoori W. H., Giovannucci E. L., Rimm E. B., Wing A. L., Willett W. C. Use of acetaminophen and nonsteroidal anti-inflammatory drugs: a prospective study and the risk of symptomatic diverticular disease in men. Arch Fam Med. 1998 May-Jun;7(3):255–260. doi: 10.1001/archfami.7.3.255. [DOI] [PubMed] [Google Scholar]
  4. Ambrosetti P., Robert J. H., Witzig J. A., Mirescu D., Mathey P., Borst F., Rohner A. Acute left colonic diverticulitis in young patients. J Am Coll Surg. 1994 Aug;179(2):156–160. [PubMed] [Google Scholar]
  5. Barcelo A., Claustre J., Moro F., Chayvialle J. A., Cuber J. C., Plaisancié P. Mucin secretion is modulated by luminal factors in the isolated vascularly perfused rat colon. Gut. 2000 Feb;46(2):218–224. doi: 10.1136/gut.46.2.218. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Beaver T. M., Fullerton D. A., Zamora M. R., Badesch D. B., Weill D., Brown J. M., Campbell D. N., Grover F. L. Colon perforation after lung transplantation. Ann Thorac Surg. 1996 Sep;62(3):839–843. doi: 10.1016/s0003-4975(96)00393-1. [DOI] [PubMed] [Google Scholar]
  7. Campbell K., Steele R. J. Non-steroidal anti-inflammatory drugs and complicated diverticular disease: a case-control study. Br J Surg. 1991 Feb;78(2):190–191. doi: 10.1002/bjs.1800780218. [DOI] [PubMed] [Google Scholar]
  8. Candelas G., Jover J. A., Fernandez B., Rodriguez-Olaverri J. C., Calatayud J. Perforation of the sigmoid colon in a rheumatoid arthritis patient treated with methylprednisolone pulses. Scand J Rheumatol. 1998;27(2):152–153. doi: 10.1080/030097498441056. [DOI] [PubMed] [Google Scholar]
  9. Canter J. W., Shorb P. E., Jr Acute perforation of colonic diverticula associated with prolonged adrenocorticosteroid therapy. Am J Surg. 1971 Jan;121(1):46–51. doi: 10.1016/0002-9610(71)90076-6. [DOI] [PubMed] [Google Scholar]
  10. Cavallaro V., Catania V., Bonaccorso R., Mazzone S., Speciale A., Di Marco R., Blandino G., Caccamo F. Effect of a broad-spectrum cephalosporin on the oral and intestinal microflora in patients undergoing colorectal surgery. J Chemother. 1992 Apr;4(2):82–87. doi: 10.1080/1120009x.1992.11739145. [DOI] [PubMed] [Google Scholar]
  11. Corder A. Steroids, non-steroidal anti-inflammatory drugs, and serious septic complications of diverticular disease. Br Med J (Clin Res Ed) 1987 Nov 14;295(6608):1238–1238. doi: 10.1136/bmj.295.6608.1238. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Coutrot S., Roland D., Barbier J., Van Der Marcq P., Alcalay M., Matuchansky C. Acute perforation of colonic diverticula associated with short-term indomethacin. Lancet. 1978 Nov 11;2(8098):1055–1056. doi: 10.1016/s0140-6736(78)92385-1. [DOI] [PubMed] [Google Scholar]
  13. Cryer B. NSAID gastrointestinal toxicity. Curr Opin Gastroenterol. 2000 Nov;16(6):495–502. doi: 10.1097/00001574-200011000-00006. [DOI] [PubMed] [Google Scholar]
  14. Cummings J. H., Stephen A. M. The role of dietary fibre in the human colon. Can Med Assoc J. 1980 Dec 6;123(11):1109–1114. [PMC free article] [PubMed] [Google Scholar]
  15. Davies N. M. Review article: non-steroidal anti-inflammatory drug-induced gastrointestinal permeability. Aliment Pharmacol Ther. 1998 Apr;12(4):303–320. doi: 10.1046/j.1365-2036.1998.00300.x. [DOI] [PubMed] [Google Scholar]
  16. Davies N. M. Toxicity of nonsteroidal anti-inflammatory drugs in the large intestine. Dis Colon Rectum. 1995 Dec;38(12):1311–1321. doi: 10.1007/BF02049158. [DOI] [PubMed] [Google Scholar]
  17. Davies N. M., Wallace J. L. Nonsteroidal anti-inflammatory drug-induced gastrointestinal toxicity: new insights into an old problem. J Gastroenterol. 1997 Feb;32(1):127–133. doi: 10.1007/BF01213310. [DOI] [PubMed] [Google Scholar]
  18. Day T. K. Intestinal perforation associated with osmotic slow release indomethacin capsules. Br Med J (Clin Res Ed) 1983 Dec 3;287(6406):1671–1672. doi: 10.1136/bmj.287.6406.1671-a. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Eastwood M. A., Smith A. N., Brydon W. G., Pritchard J. Comparison of bran, ispaghula, and lactulose on colon function in diverticular disease. Gut. 1978 Dec;19(12):1144–1147. doi: 10.1136/gut.19.12.1144. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Edlund C., Nord C. E. Effect on the human normal microflora of oral antibiotics for treatment of urinary tract infections. J Antimicrob Chemother. 2000 Sep;46 (Suppl 1):41–65. [PubMed] [Google Scholar]
  21. Elliott T. B., Yego S., Irvin T. T. Five-year audit of the acute complications of diverticular disease. Br J Surg. 1997 Apr;84(4):535–539. [PubMed] [Google Scholar]
  22. Ferzoco L. B., Raptopoulos V., Silen W. Acute diverticulitis. N Engl J Med. 1998 May 21;338(21):1521–1526. doi: 10.1056/NEJM199805213382107. [DOI] [PubMed] [Google Scholar]
  23. Finlay I. G., Carter D. C. A comparison of emergency resection and staged management in perforated diverticular disease. Dis Colon Rectum. 1987 Dec;30(12):929–933. doi: 10.1007/BF02554278. [DOI] [PubMed] [Google Scholar]
  24. Finnie I. A., Dwarakanath A. D., Taylor B. A., Rhodes J. M. Colonic mucin synthesis is increased by sodium butyrate. Gut. 1995 Jan;36(1):93–99. doi: 10.1136/gut.36.1.93. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Frantzides C. T., Condon R. E., Schulte W. J., Cowles V. Effects of morphine on colonic myoelectric and motor activity in subhuman primates. Am J Physiol. 1990 Feb;258(2 Pt 1):G247–G252. doi: 10.1152/ajpgi.1990.258.2.G247. [DOI] [PubMed] [Google Scholar]
  26. Frantzides C. T., Cowles V., Salaymeh B., Tekin E., Condon R. E. Morphine effects on human colonic myoelectric activity in the postoperative period. Am J Surg. 1992 Jan;163(1):144–149. doi: 10.1016/0002-9610(92)90267-u. [DOI] [PubMed] [Google Scholar]
  27. Gibson G. R. Dietary modulation of the human gut microflora using prebiotics. Br J Nutr. 1998 Oct;80(4):S209–S212. [PubMed] [Google Scholar]
  28. Ginaldi L., De Martinis M., D'Ostilio A., Marini L., Loreto M. F., Corsi M. P., Quaglino D. The immune system in the elderly: I. Specific humoral immunity. Immunol Res. 1999;20(2):101–108. doi: 10.1007/BF02786466. [DOI] [PubMed] [Google Scholar]
  29. Hart A. R., Kennedy H. J., Stebbings W. S., Day N. E. How frequently do large bowel diverticula perforate? An incidence and cross-sectional study. Eur J Gastroenterol Hepatol. 2000 Jun;12(6):661–665. doi: 10.1097/00042737-200012060-00016. [DOI] [PubMed] [Google Scholar]
  30. Hinchey E. J., Schaal P. G., Richards G. K. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978;12:85–109. [PubMed] [Google Scholar]
  31. Hirose Y., Sugie S., Yoshimi N., Matsunaga K., Hara A., Mori H. Induction of apoptosis in colonic epithelium treated with 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) and its modulation by a P4501A2 inducer, beta-naphthoflavone, in male F344 rats. Cancer Lett. 1998 Jan 30;123(2):167–172. doi: 10.1016/s0304-3835(97)00413-8. [DOI] [PubMed] [Google Scholar]
  32. Hughes L. E. Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis. Gut. 1969 May;10(5):336–344. doi: 10.1136/gut.10.5.336. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Imperiali G., Meucci G., Alvisi C., Fasoli R., Ferrara A., Girelli C. M., Rocca F., Saibeni S., Minoli G. Segmental colitis associated with diverticula: a prospective study. Gruppo di Studio per le Malattie Infiammatorie Intestinali (GSMII). Am J Gastroenterol. 2000 Apr;95(4):1014–1016. doi: 10.1111/j.1572-0241.2000.01943.x. [DOI] [PubMed] [Google Scholar]
  34. Kronborg O. Treatment of perforated sigmoid diverticulitis: a prospective randomized trial. Br J Surg. 1993 Apr;80(4):505–507. doi: 10.1002/bjs.1800800434. [DOI] [PubMed] [Google Scholar]
  35. Langman M. J., Morgan L., Worrall A. Use of anti-inflammatory drugs by patients admitted with small or large bowel perforations and haemorrhage. Br Med J (Clin Res Ed) 1985 Feb 2;290(6465):347–349. doi: 10.1136/bmj.290.6465.347. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Levi S., Shaw-Smith C. Non-steroidal anti-inflammatory drugs: how do they damage the gut? Br J Rheumatol. 1994 Jul;33(7):605–612. doi: 10.1093/rheumatology/33.7.605. [DOI] [PubMed] [Google Scholar]
  37. Macfarlane G. T., Macfarlane S. Human colonic microbiota: ecology, physiology and metabolic potential of intestinal bacteria. Scand J Gastroenterol Suppl. 1997;222:3–9. doi: 10.1080/00365521.1997.11720708. [DOI] [PubMed] [Google Scholar]
  38. Manousos O., Day N. E., Tzonou A., Papadimitriou C., Kapetanakis A., Polychronopoulou-Trichopoulou A., Trichopoulos D. Diet and other factors in the aetiology of diverticulosis: an epidemiological study in Greece. Gut. 1985 Jun;26(6):544–549. doi: 10.1136/gut.26.6.544. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Mariadason J. M., Catto-Smith A., Gibson P. R. Modulation of distal colonic epithelial barrier function by dietary fibre in normal rats. Gut. 1999 Mar;44(3):394–399. doi: 10.1136/gut.44.3.394. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Mäkelä J., Vuolio S., Kiviniemi H., Laitinen S. Natural history of diverticular disease: when to operate? Dis Colon Rectum. 1998 Dec;41(12):1523–1528. doi: 10.1007/BF02237300. [DOI] [PubMed] [Google Scholar]
  41. Nagorney D. M., Adson M. A., Pemberton J. H. Sigmoid diverticulitis with perforation and generalized peritonitis. Dis Colon Rectum. 1985 Feb;28(2):71–75. doi: 10.1007/BF02552645. [DOI] [PubMed] [Google Scholar]
  42. Painter N. S., Burkitt D. P. Diverticular disease of the colon, a 20th century problem. Clin Gastroenterol. 1975 Jan;4(1):3–21. [PubMed] [Google Scholar]
  43. Painter N. S. The effect of neostigmine methyl sulphate on the human colon in health and in diverticulosis. Proc R Soc Med. 1967 Mar;60(3):219–220. [PMC free article] [PubMed] [Google Scholar]
  44. Parks T. G. Natural history of diverticular disease of the colon. Clin Gastroenterol. 1975 Jan;4(1):53–69. [PubMed] [Google Scholar]
  45. Peoples J. B., Vilk D. R., Maguire J. P., Elliott D. W. Reassessment of primary resection of the perforated segment for severe colonic diverticulitis. Am J Surg. 1990 Mar;159(3):291–294. doi: 10.1016/s0002-9610(05)81220-6. [DOI] [PubMed] [Google Scholar]
  46. Rao S. S., Beaty J., Chamberlain M., Lambert P. G., Gisolfi C. Effects of acute graded exercise on human colonic motility. Am J Physiol. 1999 May;276(5 Pt 1):G1221–G1226. doi: 10.1152/ajpgi.1999.276.5.G1221. [DOI] [PubMed] [Google Scholar]
  47. Routes J., Claman H. N. Corticosteroids in inflammatory bowel disease. A review. J Clin Gastroenterol. 1987 Oct;9(5):529–535. doi: 10.1097/00004836-198710000-00008. [DOI] [PubMed] [Google Scholar]
  48. Sarna S. K. Physiology and pathophysiology of colonic motor activity (2). Dig Dis Sci. 1991 Jul;36(7):998–1018. doi: 10.1007/BF01297155. [DOI] [PubMed] [Google Scholar]
  49. Sasaki D., Munakata A., Saitoh Y., Yoshida Y. Anti-spasmodic effect of prifinium bromide on the proximal and distal colon in patients with diverticular disease. Gastroenterol Jpn. 1981;16(4):344–349. doi: 10.1007/BF02774466. [DOI] [PubMed] [Google Scholar]
  50. Schang J. C., Hémond M., Hébert M., Pilote M. How does morphine work on colonic motility? An electromyographic study in the human left and sigmoid colon. Life Sci. 1986 Feb 24;38(8):671–676. doi: 10.1016/0024-3205(86)90580-1. [DOI] [PubMed] [Google Scholar]
  51. Schauer P. R., Ramos R., Ghiatas A. A., Sirinek K. R. Virulent diverticular disease in young obese men. Am J Surg. 1992 Nov;164(5):443–448. doi: 10.1016/s0002-9610(05)81177-8. [DOI] [PubMed] [Google Scholar]
  52. Schoetz D. J., Jr Diverticular disease of the colon: a century-old problem. Dis Colon Rectum. 1999 Jun;42(6):703–709. doi: 10.1007/BF02236921. [DOI] [PubMed] [Google Scholar]
  53. Schwartz H. A. Lower gastrointestinal side effects of nonsteroidal antiinflammatory drugs. J Rheumatol. 1981 Nov-Dec;8(6):952–954. [PubMed] [Google Scholar]
  54. Sesink A. L., Termont D. S., Kleibeuker J. H., Van der Meer R. Red meat and colon cancer: the cytotoxic and hyperproliferative effects of dietary heme. Cancer Res. 1999 Nov 15;59(22):5704–5709. [PubMed] [Google Scholar]
  55. Sheers R., Williams W. R. NSAIDs and gut damage. Lancet. 1989 Nov 11;2(8672):1154–1154. doi: 10.1016/s0140-6736(89)91515-8. [DOI] [PubMed] [Google Scholar]
  56. The intraluminal pressure patterns in diverticulosis of the colon: Part II The effect of morphine. Gut. 1964 Jun;5(3):207–213. doi: 10.1136/gut.5.3.207. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Tudor R. G., Farmakis N., Keighley M. R. National audit of complicated diverticular disease: analysis of index cases. Br J Surg. 1994 May;81(5):730–732. doi: 10.1002/bjs.1800810537. [DOI] [PubMed] [Google Scholar]
  58. Tyau E. S., Prystowsky J. B., Joehl R. J., Nahrwold D. L. Acute diverticulitis. A complicated problem in the immunocompromised patient. Arch Surg. 1991 Jul;126(7):855–859. doi: 10.1001/archsurg.1991.01410310065009. [DOI] [PubMed] [Google Scholar]
  59. Watters D. A., Smith A. N. Strength of the colon wall in diverticular disease. Br J Surg. 1990 Mar;77(3):257–259. doi: 10.1002/bjs.1800770308. [DOI] [PubMed] [Google Scholar]
  60. Weiner H. L., Rezai A. R., Cooper P. R. Sigmoid diverticular perforation in neurosurgical patients receiving high-dose corticosteroids. Neurosurgery. 1993 Jul;33(1):40–43. doi: 10.1227/00006123-199307000-00006. [DOI] [PubMed] [Google Scholar]
  61. Wilson R. G., Smith A. N., Macintyre I. M. Complications of diverticular disease and non-steroidal anti-inflammatory drugs: a prospective study. Br J Surg. 1990 Oct;77(10):1103–1104. doi: 10.1002/bjs.1800771008. [DOI] [PubMed] [Google Scholar]
  62. Wong W. D., Wexner S. D., Lowry A., Vernava A., 3rd, Burnstein M., Denstman F., Fazio V., Kerner B., Moore R., Oliver G. Practice parameters for the treatment of sigmoid diverticulitis--supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 2000 Mar;43(3):290–297. doi: 10.1007/BF02258291. [DOI] [PubMed] [Google Scholar]
  63. Zeitoun G., Laurent A., Rouffet F., Hay J., Fingerhut A., Paquet J., Peillon C., Research T. F. Multicentre, randomized clinical trial of primary versus secondary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitis. Br J Surg. 2000 Oct;87(10):1366–1374. doi: 10.1046/j.1365-2168.2000.01552.x. [DOI] [PubMed] [Google Scholar]

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