original papers - Advances in Clinical and Experimental Medicine

original papers - Advances in Clinical and Experimental Medicine

orIginal papers
Adv Clin Exp Med 2011, 20, 5, 623–626
ISSN 1230-025X
© Copyright by Wroclaw Medical University
Katarzyna Neubauer1, Robert Dudkowiak2, Radosław Kempiński1, Adam Bąk3,
Leszek Paradowski1
Colonic Diverticulosis and Risk of Large Bowel Adenomas
Uchyłkowatość jelita grubego a ryzyko występowania
gruczolaków jelita grubego
Department of Gastroenterology and Hepatology, Wroclaw Medical University, Poland
Dietetics Division at Department of Gastroenterology and Hepatology, Wroclaw Medical University, Poland
3
resident on gastroenterology in the Department of Gastroenterology and Hepatology,
Wroclaw Medical University, Poland
1
2
Abstract
Background. The problem of the colonic diverticulosis, one of the most common diseases of the large bowel, as
a risk factor for colonic adenomas and adenocarcinomas has not been fully clarified. The published results of the
studies regarding this problem are contradictory.
Objectives. Evaluating the relationship between colonic diverticulosis and colonic adenomas.
Material and Methods. The group studied consisted of 3011 consecutive patients (1776 women, 1235 men, age
17–100 years, mean age 52.50 ± 16.36) which had endoscopic examination of the large bowel in the Endoscopy
unit of the Department of Gastroenterology and Hepatology, Wroclaw Medical University. Retrospective analysis
encompassed age, gender, presence and location of diverticula and presence and location of adenomas and adenocarcinomas.
Results. Diverticula were found in 425 patients (14.11%). Adenomas were found in 65 (15.3%) patients with diverticulosis and 190 (7.3%) patients without diverticulosis (OR = 2.28). Left-sided adenomas were found in 44 (10.35%)
patients with left-sided diverticula and in 127 (4.9%) patients without diverticulosis (OR = 2.4). Colorectal cancer
was present in 2.82% (n = 12) of patients with diverticulosis and in 3.79% (n = 98) of patients without diverticulosis. The presence of adenomas in relation to the presence of diverticula was statistically significant (chi-square
analysis; p < 0.001). The presence of colorectal cancer in relation to the presence of diverticula was not statistically
significant (p = 0.219).
Conclusions. The results of our study suggest that the presence of left-sided colonic diverticula may be considered
as a risk factor for colonic adenomas (Adv Clin Exp Med 2011, 20, 5, 623–626).
Key words: colonic diverticulosis, colonic adenomas.
Streszczenie
Wprowadzenie. Nie wyjaśniono jednoznacznie, czy uchyłkowatość jelita grubego, jedna z najczęstszych chorób
okrężnicy, stanowi czynnik ryzyka rozwoju gruczolaków jelita grubego. Opublikowane wyniki badań poświęconych temu problemowi są sprzeczne.
Cel pracy. Ocena związku między uchyłkami i gruczolakami jelita grubego.
Materiał i metody. Grupę badaną tworzyło 3011 kolejnych pacjentów (1776 kobiet, 1235 mężczyzn, w wieku
17–100 lat, średni wiek 52,50 ± 16,36), u których przeprowadzono badanie endoskopowe jelita grubego w pracowni endoskopowej Kliniki Gastroenterologii i Hepatologii AM we Wrocławiu. W retrospektywnej analizie oceniano:
wiek, płeć, obecność i umiejscowienie uchyłków, obecność i umiejscowienie gruczolaków i gruczolakoraków.
Wyniki. Uchyłki stwierdzono u 425 (14,11%) pacjentów, a gruczolaki – u 44 (10,7%) pacjentów z uchyłkowatością
i 127 (4,9%) pacjentów bez uchyłkowatości. Raka jelita grubego rozpoznano u 2,82 (n = 12) pacjentów z uchyłkowatością i 3,79% (n = 98) pacjentów bez uchyłkowatości. Obecność gruczolaków w zależności od obecności
uchyłków była istotna statystycznie (test c2; p < 0,001). Obecność raka jelita grubego w zależności od występowania
uchyłków nie była istotna statystycznie (p = 0,219).
Wnioski. Wyniki badania własnego sugerują, że uchyłki w lewej połowie jelita grubego mogą być uważane za
czynnik ryzyka gruczolaków jelita grubego (Adv Clin Exp Med 2011, 20, 5, 623–626).
Słowa kluczowe: uchyłkowatość jelita grubego, gruczolaki jelita grubego.
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K. Neubauer et al.
Epidemiological studies have demonstrated
that there is an increase in the prevalence of colonic diverticulosis and colorectal cancer in Western countries.
The incidence of colonic diverticulosis increases with age and thus this condition is the most
common structural abnormality of colon in the elderly. Despite its prevalence, the etiopathogenesis
of colonic diverticulosis remains unclear. Painter
and Burkitt described this condition as a fiber deficiency disease of Western civilization [1]. Additionally, some experimental and epidemiological
studies have also demonstrated the crucial role of
fiber deficiency in diverticula development. Even
so, the exact role of fiber in the disease pathogenesis is not fully elucidated and remains controversial [2]. In Western countries, diverticula most
often develop distally to the splenic flexure of the
colon. In two Polish studies, the left colon was affected with diverticulosis in 70% and 93% of cases,
respectively [3, 4]. For most of patients, diverticulosis is asymptomatic. However, diverticulosis can
be complicated with diverticulitis, bleeding and
segmental colitis associated with diverticulosis
(SCAD) [5, 6].
Colorectal cancer is the most frequent malignancy of the digestive tract. In the ranking of
incidence of malignancies, colorectal cancer is in
the second place among males and females in Poland [7]. Colonic adenomas are a well known precancerous condition. They share some features
with diverticulosis, with regard to etiological factors. First, environmental factors, mostly nutritional, are suggested to play a role in colonic adenomas
development. Second, the prevalence of colonic adenomas increases with age. Third, colonic polyps
also usually do not produce any symptoms.
However, the results of the studies regarding
the association between diverticula and polyps
are conflicting. Additionally, as dietary factors, at
least partly, are implicated in diverticulosis and
colorectal cancer etiology, they cannot be extrapolated from other geographical areas, where people
have a different diet.
The study was aimed to evaluate the relationship between colonic diverticulosis and adenomas.
Material and Methods
The group studied consisted of 3011 consecutive patients (1776 women, 1235 men, age
17–100 years, mean age 52.50 ± 16.36) which had
endoscopic examination of the large bowel in the
Endoscopic unit of the Department of Gastroenterology and Hepatology, Wroclaw Medical University. Retrospective analysis encompassed age
and gender of patients, the presence and location
of diverticula and adenomas and the presence of
adenocarcinomas.
Findings located proximally to the splenic
flexure were considered as right-sided and the
findings located distally to the splenic flexure were
considered as left-sided.
Results
Diverticula were found in 425 patients
(14.11%). Diverticula in the sigmoid and descending colon were observed in 93.41% and 37.17% of
those patients, respectively.
The mean age of patients with diverticulosis
(65.96 ± 10.72) was higher than the mean age of
patients without diverticulosis (p < 0.01). The
mean age of patients with polyps (67.62 ± 9.849)
was higher than the mean age of patients without
polyps (p = 0.0000). The mean age of patients with
CRC (62.19 ± 12.89) was higher than the mean age
of patients without CRC (p = 0.0000).
Adenomas were found in 65 (15.3%) patients
with diverticulosis and 190 (7.3%) patients without diverticulosis (OR = 2.28) (Fig. 1). Left-sided
adenomas were found in 44 (10.35%) patients with
left-sided diverticula and in 127 (4.9%) patients
without diverticulosis (OR = 2.4). The location
and pathological type of polyps are presented in
Table 1.
Colorectal cancer was present in 2.82% (n = 12)
of patients with diverticulosis and in 3.79%
(n = 98) of patients without diverticulosis. The
presence of colorectal cancer in relation to the
presence of diverticula was not statistically significant (p = 0.219).
studied group (n = 3011)
diverticula (n = 425; 14.11%)
adenomas (n = 65; 15.3%)
no adenomas (n = 360; 84.7%)
no diverticula (n = 2856; 85.89%)
adenomas (n = 190; 7.3%) no adenomas (n = 2396; 9.27%)
Fig. 1. Prevalence of diverticula and adenomas in the study group
Ryc. 1. Występowanie uchyłków i gruczolaków w grupie badanej
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Colonic Diverticulosis and Adenomas
Table 1. Localization and pathological type of adenomas
in patients with diverticulosis
Tabela 1. Umiejscowienie i histopatologiczny typ
gruczolaków u pacjentów z uchyłkowatością
Adenomas (Gruczolaki)
AV
ATV
AT
Rectum (Odbytnica)
4
2
8
Sigmoid colon (Esica)
2
1
23
Descending colon
(Zstępnica)
0
0
4
Transverse colon
(Poprzecznica)
2
0
8
Ascending colon
(Wstępnica)
0
0
6
Caecum (Kątnica)
1
0
4
Total (Razem)
9
3
53
AV – villous adenoma.
ATV – tubulovillous adenoma.
AT – tubular adenoma.
AV – gruczolak kosmkowy.
ATV – gruczolak cewkowo-kosmkowy.
AT – gruczolak cewkowy.
Discussion
Our study has demonstrated that colonic adenomas, constituting a risk factor of colorectal cancer, are found more often in patients with colonic
diverticulosis than in patients without colonic diverticulosis.
The association of diverticulosis and adenomas
may hypothetically results from the fact that, first,
the prevalence of both conditions increases with
age, and second, a dietary factor is suggested to
play a role in the development of them. The results of studies regarding the association between
colonic diverticulosis and adenomas are conflicting. Moreover, as environmental factors may play
a role in the pathogenesis of the studied conditions,
the results of the studies conducted in other geographical areas cannot be extrapolated to Poland.
Additionally, the location of diverticulosis in the
large bowel also differs among the inhabitants of
different regions of the world. Diverticulosis typically is left-sided in culturally-Western countries
and right-sided in Asian communities.
As reviewed by Morini et al., the following
factors may be implicated in the relationship between colonic diverticulosis and colorectal cancer:
age, a diet low in fiber and rich in fat, chronic inflammation, being a risk factor of colorectal cancer, which is present in diverticulosis, disturbances
in the extracellular matrix found in both diseases,
dysregulation of cell proliferations found in both
diseases.
However, the authors summarize that strong
evidence is missing to recommend a different
clinical approach in patients with diverticulosis
regarding CRC prevention [8].
Our findings support the hypothesis that the
presence of diverticula should be included in the
evaluation of a risk of colorectal cancer. However,
Krones et al. found a significantly reduced rate
of diverticulosis in patients with colonic cancer
(n = 1326) and a reduced rate of colonic cancer in
patients with diverticulitis (n = 512). The authors
concluded that, as the extracellular matrix may play
a role in the development of diverticula and cancer,
the observed result can be a consequence of different local milieu [9]. On the other hand, Hirata
et al. demonstrated that patients with diverticulosis
have a 1.7-fold increased risk of colonic adenomatous polyps as compared to those without. This
study was conducted in Japan, where diverticulosis mostly affects the right colon, similar to other
Asian countries. Additionally, the authors suggested that, regardless of the segment with diverticular
disease or race, patients with diverticular disease
have a higher risk of colonic neoplasia [10]. In another study, Meurs-Szojda et al. did not find any
relationship between diverticulosis and polyps and/
/or colorectal cancer. The authors analyzed 4241
colonoscopies. Diverticulosis was diagnosed in 25%
of patients and polyps in 30% of patients [11].
Dietary factors, as well as being overweight
and obesity, seem to be implicated in the pathogenesis of both of the conditions studied, colonic
diverticulosis and adenomas/adenocarcinomas.
For example, visceral obesity and insulin resistance have been demonstrated to be risk factors
for colorectal adenoma [12]. Central obesity and
dyslipidemia were found to be independent risk
factors for colorectal adenoma in 4122 Chinese
individuals [13]. The increased risk of colorectal
adenoma in subjects with abdominal obesity was
also suggested by the results of a study conducted
by Kim et al. in South Korea [14]. A high intake
of fruits and vegetables and lower intakes of red
and processed meat seem to protect against colorectal adenoma. Moreover, a higher intake of red
and processed meat, potatoes and refined carbohydrates is related to a higher risk of colorectal
adenoma [15]. Many studies have suggested that
dietary factors participate in the development of
colonic diverticulosis [16–18]. In a Polish study,
42.7% of patients with diverticulosis were found to
be overweight and 17.1% were obese [19]. Yet the
role of diet in the development of the one of the
most common diseases of the large bowel has not
been fully clarified [20].
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K. Neubauer et al.
The limitation of our study is the fact that the
study group consisted of hospitalized, symptomatic patients. It would be interesting to test the relationship between diverticulosis and adenomas in
asymptomatic individuals, e.g. people participating in a colorectal cancer screening program.
Patients with diverticulosis were shown to
have a higher risk of colonic adenomas when compared to patients without diverticulosis. Based on
our findings, the presence of diverticulosis should
be included in the colonic adenomas risk stratification.
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Address for correspondence:
Katarzyna Neubauer
Department of Gastroenterology and Hepatology
Wroclaw Medical University
Borowska 213
50-556 Wrocław
Poland
Tel.: +48 71 733 21 20
E-mail: [email protected]
Conflict of interest: None declared
Received: 29.07.2011
Revised: 23.08.2011
Accepted: 5.10.2011