Intest Res.  2025 Jan;23(1):96-106. 10.5217/ir.2024.00046.

Bowel movement alterations predict the severity of diverticular disease and the risk of acute diverticulitis: a prospective, international study

• Tursi A
• Piovani D
• Brandimarte G
• Di Mario F
• Elisei W
• Picchio M
• Figlioli G
• Bassotti G
• Allegretta L
• Annunziata ML
• Bafutto M
• Bianco MA
• Colucci R
• Conigliaro R
• Dumitrascu DL
• Escalante R
• Ferrini L
• Forti G
• Franceschi M
• Graziani MG
• Lammert F
• Latella G
• Lisi D
• Maconi G
• Compare D
• Nardone G
• Camara de Castro Oliveira L
• Enio CO
• Papagrigoriadis S
• Pietrzak A
• Pontone S
• Stundiene I
• Poškus T
• Pranzo G
• Reichert MC
• Rodino S
• Regula J
• Scaccianoce G
• Scaldaferri F
• Vassallo R
• Zampaletta C
• Zullo A
• Spaziani E
• Bonovas S
• Papa A
• Danese S
• DICA International Group

• KMID: 2564400
• DOI: http://doi.org/10.5217/ir.2024.00046

Abstract

Background/Aims
Patients with diverticular disease (DD) frequently have abnormal bowel movements. However, it is unknown whether the entity of these alterations is associated with the severity of DD. We aimed to assess bowel habits and their relationship with the severity of DD according to Diverticular Inflammation and Complication Assessment (DICA) classification, Combined Overview on Diverticular Assessment (CODA) score, and fecal calprotectin (FC).
Methods
An international, multicenter, prospective cohort study was conducted in 43 centers. A 10-point visual analog scale (VAS) was used to assess the severity of constipation and diarrhea. The association of constipation and diarrhea with DICA classification, CODA score, and basal FC was tested using non-parametric tests. Survival methods for censored observations were applied to test the association of constipation and diarrhea with the incidence of acute diverticulitis over a 3-year follow-up.
Results
Of 871 patients with DD were included in the study. Of these, 208 (23.9%) and 199 (22.9%) reported a VAS score for constipation and diarrhea at least 3 at baseline, respectively. Higher constipation and diarrhea scores were associated with increasing DICA classification, CODA score and basal FC (P< 0.001). Constipation and diarrhea scores were independently associated with an increased hazard of developing acute diverticulitis (hazard ratio [HR]_constipation = 1.15 per 1-VAS point increase, 95% confidence interval [CI], 1.04–1.27; P=0.004; and HR_diarrhea =1.14; 95% CI, 1.03–1.26; P=0.014, respectively).
Conclusions
In newly diagnosed patients with DD, higher endoscopic and combined scores of DD severity were associated with higher scores of constipation and diarrhea at baseline. Both constipation and diarrhea were independent prognostic factors of acute diverticulitis.

Keyword

Bowel frequency; Diverticular diseases; Diverticular Inflammation and Complication Assessment classification; Fecal calprotectin; Acute diverticulitis

Figure

• 

  Fig. 1. Box plots showing the distribution of symptoms scores for constipation and diarrhea (10-point VAS) across groups of patients def ined by DICA endoscopic classification levels (A, B), CODA score (C, D), and basal FC (E, F). Constipation and diarrhea 10-point VASs were tested as continuous variables across the DICA classification levels and CODA scores by applying the Kruskal-Wallis test (A-D; P<0.001) and across the 2 categories of FC by using the Wilcoxon rank-sum test (E, F; P<0.01). VAS, visual analog scale; DICA, Diverticular Inflammation and Complication Assessment; CODA, Combined Overview on Diverticular Assessment; FC, fecal calprotectin.

• 

  Fig. 2. Kaplan-Meier curves of the cumulative incidence of acute diverticulitis. (A) Comparison between patients without symptoms of constipation (10-point VAS=0) and patients reporting any symptom of constipation (10-point VAS ≥1). (B) Comparison between patients without symptoms of diarrhea (10-point VAS=0) and patients reporting any diarrhea (10-point VAS ≥1). Two-sided P-values from log-rank tests are reported. VAS, visual analog scale.

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