Introduction

Natural history of colonic diverticulosis and diverticular disease (DD) is poorly known, and available data come mostly from retrospective studies. Doubts exist about DD progression, rates, and associated risk factors.

Aims & Methods

We aimed to assess the progression rate of different spectrum of DD and associated risk factors. A five-years, prospective, observational, multicenter cohort-study, with follow-up assessment scheduled every six months (Diverticular Disease Registry, REMAD) was conducted. At baseline,1217 patients were categorized: i) Diverticulosis: presence of colonic diverticula in the absence of lower abdominal symptoms; ii) Symptomatic uncomplicated diverticular disease (SUDD): recurrent abdominal symptoms as pain and/or changes in bowel habits, attributed to diverticula in absence of overt inflammation; iii) Previous diverticulitis (PD): patients who have experienced at least one episode of diverticulitis in the past. We evaluated: i) risk of SUDD among patients with baseline diverticulosis; ii) risk of diverticulitis among patients with baseline diverticulosis; iii) risk of diverticulitis among patients with baseline SUDD; iv) risk of recurrent diverticulitis in patients with baseline PD.
Comparison of the continuous variables was performed by Generalized Linear Mixed Model, and the association with sex was evaluated by X2 test. Kaplan-Meier analysis and the Cox hazard model (backward model) were used to identify factors associated with DD progression [age, gender, body mass index (BMI), first-degree family history of DD or colonic cancer, diet rich in fiber, active smoking, alcohol and coffee use, physical activity, medical treatments].

Results

Table 1 presents patient’s baseline demographic characteristics and length of follow-up. Compared to diverticulosis, female gender was associated to SUDD (p<0.0001) and PD (p=0.003). PD patients were younger than diverticulosis and SUDD (p=0.002 vs diverticulosis; p=0.03 vs SUDD). Over the study period, 51 patients with baseline diverticulosis developed SUDD (7.23%; 2.42 per 100 person-year) and 8 developed diverticulitis (1.13%; 0.38 per 100 person-year). Nine patients with baseline SUDD developed diverticulitis (3.0%; 0.93 per 100 person-year). Forty-six patients with baseline PD develop a recurrent diverticulitis (21.70%; 7.72 per 100 person-year). Female gender is associated with increased risk of developing diverticulitis in patients with baseline diverticulosis [HR=1.75 (95%CI: 1.04 to 2.93), p=0.035] or having recurrent diverticulitis [HR=2.73 (95%CI: 1.42 to 5.25), p=0.003]. Other factors were not associated to DD progression.

Conclusion

This prospective observational study shows a progression rate of diverticular disease increasing along with DD spectrum (i.e. from diverticulosis, SUDD, up to patients with previous diverticulitis). We also found that the only risk factor associated with disease progression was the female gender. This should be kept in mind to better address clinical practice and to stratify progression disease risk.

Introduction

Chronic constipation (CC) is managed differently across global regions due to cultural, dietary, and healthcare system differences. Emerging pharmacological options offer promise, yet real-world adoption remains limited by systemic barriers including cost and availability. This study reports findings from the Bali Chronic Constipation Roundtable, which was conducted in November 2024 to examine the regional practices in Asian and compare them to Western approaches.

Aims & Methods

A multinational expert panel representing gastroenterologists from 12 countries in East, Southeast, and South Asia convened to review survey data, real-world clinical practices, and guideline applicability. All attendees completed a questionnaire exploring the regional epidemiology and challenges related to CC. Key domains assessed included symptom profiles, diagnostic tools, treatment access and practices, and cultural perceptions.

Results

CC prevalence in Asia varied significantly, ranging from 3.5% in Indonesia to up to 40% in Taiwan. Demographic groups disproportionately affected included the elderly (81.0% of respondents), women (45.2%), and children (23.8%). The Rome IV criteria emerged as the most frequently cited CC diagnostic approach (71.4%), followed by physician diagnosis (61.9%), local criteria (19.0%), and Bristol Stool Chart (4.8%). Experts opined that CC prevalence differed based on these varying definitions. Due to regional variations in symptom interpretation, patients frequently associate constipation with predominant symptoms like sensation of incomplete evacuation in Asia (72.1-96.5%) rather than hard stools in Western countries (81.7-100%). Strict adherence to ROME criteria might exclude patients without significant pain, potentially underdiagnosing cases. Colonic transit time is also significantly different in Asia (15.8-24.5 hours) compared to Western countries (30.0-40.0 hours), and similarly for fibre intake (9.7g/day in Asia, 16.0g/day in the USA) owing to regional dietary differences.
In terms of accessibility, experts highlighted a lack of representativeness in internet-based surveys in Asia in rural populations, causing underreporting in population-level data. 100% of respondents expressed a gap in the availability of diagnostic tools and pharmacotherapy in Asia. Access to anorectal manometry and colonic transit studies was limited in lower-resource settings, hindering diagnosis and management. The main challenges were lack of specialized centres (76.2%), patient adherence (66.7%), cost (61.9%), and access to diagnostic tools (57.1%). In terms of pharmacological therapy, osmotic laxatives were the most commonly used initial therapy in CC management (86.7% of respondents), while newer agents such as IBAT inhibitors showed efficacy in refractory cases. However, the use of newer agents was limited due to cost (76.2%) and availability (38.1%).

Key Differences in Chronic Constipation: East and West

Conclusion

Significant differences exist between Asian and Western CC management. Regionally adapted diagnostic criteria and treatment pathways are urgently needed to reflect real-world practice and improve care across Asia.

References

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2. Patimah AW, Lee YY, Dariah MY. Frequency patterns of core constipation symptoms among the Asian adults: a systematic review. BMC gastroenterology. 2017 Dec;17:1-2.
3. Jaruvongvanich V, Patcharatrakul T, Gonlachanvit S. Prediction of delayed colonic transit using Bristol stool form and stool frequency in Eastern constipated patients: a difference from the West. Journal of Neurogastroenterology and Motility. 2017 Oct 30;23(4):561.
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Introduction

Irritable bowel syndrome (IBS) is a prevalent disorder of gut-brain interaction characterized by abdominal pain and altered bowel movements. While the pathophysiology underlying IBS is incompletely understood, local allergic reactions to foods are a candidate mechanism. Confocal laser endomicroscopy (CLE) has shown acute alterations of the duodenal epithelium in IBS within minutes of local food administration and these findings have been used to identify foods contributing to IBS symptoms. However, the mechanisms and relevance of the observed alterations remain elusive.

Aims & Methods

Aim: To visualize the effect of local food administration on the duodenal mucosa using CLE and assess whether visible changes are associated with altered permeability or markers of mast cell activation ex vivo.
Methods: Non-constipated Rome IV IBS patients with negative serum specific IgE for tested foods underwent baseline gastroscopy (EGD) and CLE performed during a second EGD. Duodenal mucosa was visualized using CLE at baseline and after luminal administration of foods (egg white, soy, milk, wheat, lyophilized fish and shellfish, and nuts solutions sequentially applied in a random order) through the working channel. Altered mucosa was defined as leakage of fluorescein into the lumen and presence of particles (previously termed “cell shedding”). Serum samples were taken at index endoscopy and 30 minutes after acute mucosal alterations. Biopsies were taken at index EGD and after visualized alterations to measure transepithelial electrical resistance (TEER) in Ussing chambers and tryptase levels in biopsy supernatants. Data are reported as mean ± SEM or median and IQR as appropriate.

Results

45 CLE exams were carried out in 28 patients (age 35±2 y, 93%f, BMI 24±1 kg/m2, mean IBS symptom severity score 320±20).
At baseline, mucosal alterations were present in 9% of exams (n=4), whereas all other exams (n=41) demonstrated alterations after food administration. The highest rate of acute alterations was observed after fish/shellfish mix (50%; 10 altered / 20 exposed). The rate of observed alterations per food is presented in the table. TEER was not altered after observed alterations vs baseline (25±0.8 Ωxcm² vs 25±1 Ωxcm²). Serum tryptase was not altered after food exposure vs baseline (ratio after/before = 0.9, IQR= 0.8-1.1, n=13). Tryptase release from biopsies increased after exposure compared to baseline in 5/9 (56%) of patients after one hour and in 13/19 (68%) patients after 24h. Overall, the average tryptase release of the tissue was 1.48-fold increased after food exposure compared to baseline in the first hour after exposure (IQR = 0.3-2.1, n=9) and 1.29-fold following 24h incubation (IQR = 0.9-2.1, n = 19).

Conclusion

In this group of IBS patients, we found a high rate of acute food-induced mucosal alterations as visualized with CLE. Ex vivo permeability was unaltered after observed alterations vs. baseline. Systemic tryptase remained unchanged after acute alterations compared to baseline whereas tryptase release from biopsies was increased following food exposure compared to baseline in more than half of patients.