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.

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Spectrum 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).

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Spectrum 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.
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                                                                                Prevalence and clinical features of colonic diverticulosis
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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
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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/
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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
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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
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                                                                               clinical significance. Clin Radiol. 1998;53:842–4. https://
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conducted according to the research guidelines of King Fahad                   colon diverticulitis with calcified fecalith. Eurasian J
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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
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    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
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