Introduction
Lower abdominal pain in patients with diverticular disease (DD) can be very challenging in clinical practice. In fact, it is matter of debate whether symptomatic uncomplicated diverticular disease (SUDD) could be considered a disease its own or it represents the coexistence of irritable bowel syndrome (IBS) in patients with colonic diverticulosis. Moreover, after an episode of acute diverticulitis, patients may complain of chronic-recurrent lower abdominal pain, only sometimes related to a recurrent diverticulitis.
Aims & Methods
We aimed to assess clinical features of lower abdominal pain, in terms of presence, severity and characteristics of short-lasting and long-lasting, and the possible overlap with IBS in patients with SUDD and previous diverticulitis (PD). We utilized baseline data from the REMAD (Diverticular Disease Registry), a 5-yr prospective, observational, cohort study, involving 47 Italian centres. Patients who fulfilled criteria for diagnosis of SUDD (n=300) and PD (n=212) were asked to fill in questionnaires for characterization of abdominal pain in the past 6 months: i) questionnaire for short-lasting abdominal pain (<24 hours); ii) questionnaire for long-lasting abdominal pain (>24hours); iii) questionnaire for IBS following Rome III Criteria.
Results
One hundred and forty-eight SUDD and 118 PD patients fulfilled all questionnaires. Seventy-five patients out of 266 (28.2%) fulfilled criteria for IBS diagnosis following Rome III Criteria. IBS criteria were reported more frequently in SUDD (37.2%) compared to PD patients (17.1%) (p<0.001). The prevalent IBS subtype was the diarrhoea-one (IBS-D), that was more frequent in SUDD compared to PD (22.3% vs 10.2%, p=0.009), followed by the constipation subtype (IBS-C: 12.2% vs 5.9%, p=0.084) and mixed subtype (IBS-M: 2.7% vs 0.8%, p=0.268). Considering the abdominal pain pattern, several differences were found between SUDD and PD in terms of long-lasting abdominal pain characteristics. The number of episodes was significantly higher in SUDD (6.6±11.9) compared to PD patients (3.4± 6.9) (p <0.001). PD patients reported long-lasting pain more frequently localized in the lower left abdomen (p <0.001), while in SUDD it was more frequently diffuse (p= 0.008) or localized in the lower right quadrant (p=0.016). Features associated with long-lasting abdominal pain were more often reported in patients with PD than SUDD [fever (p<0.001), confinement to bed (p=0.021), medical consultations (p=0.026), antibiotic therapy (p<0.001), and hospitalization (p<0.001)]. Compared to PD, SUDD patients reported a significantly more frequent amelioration of pain with antispasmodics use (43.8% vs 36.1%, p=0.003) and a more frequent onset of long-lasting pain after acute gastrointestinal symptoms (i.e. fever, vomit or diarrhoea) (90.8% vs 72.4% p=0.002). Episodes of short-lasting abdominal pain were significantly more frequently reported in SUDD than in PD patients (90.5% vs 78.8% p = 0.007), although there were no significant differences in terms of severity, localization, and pain’s relief with defecation between the two groups of patients.
Conclusion
This study shows that less than a third of patients with diverticular disease reported an overlap with IBS. Moreover, SUDD patients have a different pattern of lower abdominal pain compared to PD (i.e. length of pain, number of episodes, localization, amelioration with antispasmodics, associated features). Recognizing these differences could help clinician’s through a correct differential diagnosis addressing the diagnostic approach and therapeutic management.