Endoscopic evaluation of the colon after an episode of diverticulitis: a call for a more selective approach

Purpose

Routine colonic evaluation is advised after an episode of diverticulitis to exclude colorectal cancer. In the recent years, the possible relation between diverticulitis and colorectal cancer has been subject of debate. The aim of this study is to evaluate the benefit of routine colonic endoscopy after an episode of diverticulitis.

Methods

Records of all consecutive patients presenting with a radiologically confirmed episode of diverticulitis between 2007 and 2010 were retrieved from an in-hospital database. Patients who subsequently underwent colonic evaluation were included. The endoscopic detection rate of hyperplastic polyps, adenomas and advanced colonic neoplasia was assessed. Findings were categorized on the basis of the most advanced lesion identified.

Results

Three hundred and seven patients presented with a radiologically confirmed primary episode of diverticulitis. Two hundred and five patients underwent colonic evaluation. Hyperplastic polyps were found in15 (6.8?%), adenomas in 18 (8.8?%) and advanced neoplastic lesions in 7 (3.4?%) patients. Only two patients had a colorectal malignancy.

Conclusion

There appears to be no benefit in performing routine colonic evaluation after an episode of diverticulitis as the incidence of colorectal cancer is almost equal to that of the general population. A more selective approach might therefore be justified. Potentially, only patients with persisting abdominal complaints after an episode of diverticulitis should be offered colonic evaluation to definitively exclude causal pathology.     

Fatty acid-inducible ANGPTL4 governs lipid metabolic response to exercise

Physical activity increases energy metabolism in exercising muscle. Whether acute exercise elicits metabolic changes in nonexercising muscles remains unclear. We show that one of the few genes that is more highly induced in nonexercising muscle than in exercising human muscle during acute exercise encodes angiopoietin-like 4 (ANGPTL4), an inhibitor of lipoprotein lipase-mediated plasma triglyceride clearance. Using a combination of human, animal, and in vitro data, we show that induction of ANGPTL4 in nonexercising muscle is mediated by elevated plasma free fatty acids via peroxisome proliferator-activated receptor-δ, presumably leading to reduced local uptake of plasma triglyceride-derived fatty acids and their sparing for use by exercising muscle. In contrast, the induction of ANGPTL4 in exercising muscle likely is counteracted via AMP-activated protein kinase (AMPK)-mediated down-regulation, promoting the use of plasma triglycerides as fuel for active muscles. Our data suggest that nonexercising muscle and the local regulation of ANGPTL4 via AMPK and free fatty acids have key roles in governing lipid homeostasis during exercise.Acute exercise greatly increases the cellular demand for ATP, oxygen, glucose, and fatty acids. To meet these demands, acute exercise is associated with marked changes in skeletal muscle activity of key transporters and enzymes involved in glucose and fatty acid transport and oxidation (1). Much of the regulation occurs via allosteric regulation and covalent modification of rate-limiting enzymes. In addition, alterations at the level of mRNA increasingly are believed to represent an important regulatory mechanism in the acute response to exercise (2). Indeed, acute exercise induces mRNA expression of many genes involved in a variety of processes, including energy metabolism, hypertrophy, and signaling (3–6). Not surprisingly, most studies have focused on the events occurring in exercising muscle. In contrast, much less is known about the exercise-induced changes in nonexercising muscle. Studies have shown that resting skeletal muscle is crucial in the removal of lactate from the circulation during high-intensity exercise (7) and also plays a role in adrenaline and noradrenaline production during exercise (8). In addition, similar to exercising muscle, resting muscle exhibits enhanced phosphorylation of mTOR following resistance exercise (9). Overall, however, the impact of exercise on metabolic processes and gene expression in nonexercising muscles remains ill-defined. It can be envisioned that exercise may elicit changes in gene expression in nonexercising muscle via circulating mediators including muscle-derived myokines and metabolites (10). The present study was undertaken to try to elucidate the role of inactive muscle in the metabolic response to acute exercise.     

Effects of the SGLT2 Inhibitor Dapagliflozin on Energy Metabolism in Patients With Type 2 Diabetes: A Randomized,Double-Blind Crossover Trial

OBJECTIVESGTL2 inhibitors increase urinary glucose excretion and have beneficial effects on cardiovascular and renal outcomes. The underlying mechanism may involve caloric restriction-like metabolic effects due to urinary glucose loss. We investigated the effects of dapagliflozin on 24-h energy metabolism and insulin sensitivity in patients with type 2 diabetes.RESEARCH DESIGN AND METHODSThere were 26 patients with type 2 diabetes randomized to a 5-week double-blind, crossover study with a 6- to 8-week washout. Indirect calorimetry was used to measure 24-h energy metabolism and the respiratory exchange ratio (RER), both by whole-room calorimetry and by ventilated hood during a two-step euglycemic-hyperinsulinemic clamp. Results are presented as the differences in least squares mean (95% CI) between treatments.RESULTSEvaluable patients (n = 24) had a mean (SD) age of 64.2 (4.6) years, BMI of 28.1 (2.4) kg/m², and HbA_1c of 6.9% (0.7) (51.7 [6.8] mmol/mol). Rate of glucose disappearance was unaffected by dapagliflozin, whereas fasting endogenous glucose production (EGP) increased by dapagliflozin (+2.27 [1.39, 3.14] μmol/kg/min, P < 0.0001). Insulin-induced suppression of EGP (–1.71 [–2.75, –0.63] μmol/kg/min, P = 0.0036) and plasma free fatty acids (–21.93% [–39.31, –4.54], P = 0.016) was greater with dapagliflozin. Twenty-four-hour energy expenditure (–0.11 [–0.24, 0.03] MJ/day) remained unaffected by dapagliflozin, but dapagliflozin reduced the RER during daytime and nighttime, resulting in an increased day-to-nighttime difference in the RER (–0.010 [–0.017, –0.002], P = 0.016). Dapagliflozin treatment resulted in a negative 24-h energy and fat balance (–20.51 [–27.90, –13.12] g/day).CONCLUSIONSDapagliflozin treatment for 5 weeks resulted in major adjustments of metabolism mimicking caloric restriction, increased fat oxidation, improved hepatic and adipose insulin sensitivity, and improved 24-h energy metabolism.