an investigation into the relationship between cigarette...

CLIN ICAL GASTROENTEROLOGY

An investigation into the relationship between cigarette

smoking and diverticular disease of the colon

CI JRISTOPI IER C JAMIESON, MB, BS, FRCSC, FACS, Mlt:I IAELJ WEJNHFRt,, BSc, MSc, JOANNE LORRAINE, MD

ABSTRACT: A retrospective study was conducted to dete rmine the re lation ,hip between cigarette smoking and di vertic ula r disease of the colon . One hundred and two patients undergoing ba rium enema were assessed for diverticular disease and smoking history. N o significant posit ive assoc iation between smoking and diverticula r disease was found. Can J Gastroenterol 1990;4(5 ): 193,195

Key Words: Barium enema, Diverticular disease, Smoking

Tabagisme et diverticulose

RESUME: Une ecude re trospective a ere effectuee afin de dete rminer le rapport existant entre !'usage de la c igarette ct la diverciculose. Cenc-deux patients Ont ete interroges Sur leur mode de vie Ct Ont subi un \avement baryte visant a reveler la presence de <livcrtic ules. Aucune assoc iation significativc n 'a etc etablie cntrc le tabagisme e t la diverticulose.

DIVERTICULAR DISEASE IS A COM

mon cond ition especia lly in the older population, occurring in more than 35% of persons over t he age of 65 (I ). The prevalence of Jiverticula r Jisease is much higher in the wesrern

world and in cerrnin eth nic groups, and increases with age (2-4 ).

The causes of divcrt1cular disease arc complicated. However, pressure changes in response to e,Hing or ncuropharmacologic cholinergic st imuli

Depamnenr of Surgery, Th<! \X!el/e$/ey 1-los/)iral, Toronto, Onumo Con-es/)ondence and reprints: Dr C)am1esrm, S,me 322 Jones B111/Ji111(. 160 Wdb/ev Srreer

East, Toronto, Ontario M4Y 1./3. Telef>hone ( 416) 926-7749 Received f())' [>uhlic,won March 28, / 990. Acce/ned Ma:, I 'i. J 990

CAis:J GASTRL1ENTER\)I V~)J 4 No 5 JL ll Y/Atl\~LJST 1990

arc genera lly acLcpted .1s re~ponsihlc for the eventual herniation nf mucosa through hn:ab in 1hc rnusck at the site of penet ration hy sm,111 arteries, wirh the formm1on of typical d ivcrricular sacs ( 4 ).

TPhaccn smoking has hcen ,mplrcated as a factor in 1he pni hogcnes1s of several gastrointestinal Jiscascs (5,6), a lrhnugh no stud ie, have looked at Its

relationship lO divert icular d isease. It was hypotherned that Ligarctte

smuk mg, through nicrn me, cou ld inc rease the colonic intrnluminal pressure and thu~ contrihute to the developmen t of diverticula. Nicotine, a signi fica nt conslltucnt of cigarettes, st imulates con tractile activity of the dista l de ccnd ing colon (7) and can be sufficiently forcefu l to c.n,se defecation in unancsthet izcd animab (8). Smoking has abo hcL'n shown to increase in test inal motili ty in humans (9).

An alternative mechanism prnpm.ed was through vascular cnmpromise ns a

result Ll l artcrillsc leros1s. Diven icul:ir disease and ancrioscli:rosi~ arc a~-

jAMIES()N er al

40 en en 0

en - 30 - ::J C 0 Cl.) -- ... CO C1> 20 a.>

- "C C C1> 10 0 .c ... -8. ;:

0- 39 40 - 49 50-59 60 - 69 70 - 79 80 -89

age

Figure 1) Prevalence of diverticular disease with age in 41 patients

TABLE 1 The number and percentage of smokers and nonsmokers with and without diverticula

Diverticula present

DivertlculCJ absent

Total patients

Smokers 27 (66%)

40 (66%)

67 (66%)

sociated in that they have the same geographic d istribution, and both affec t the o lder age group ( 10).

PATIENTS AND METHODS All patients who were referred to a

hospital rad iology department for outpatient barium enemas over a four month period were chosen for entry into a retro~pective study. Of the 200 patients contacted, 102 patients suppl ied complete and re liable smoking histories and were thus 111cluded.

The smoking d;:ica obta ined was organized into a 'pack-year' system. 'One pack-year' was defined as one package a day for one year. Nonsmokers were defined as patient~ who had never smoked cigarettes.

The barium enemas were performed by double contrast technique and were reviewed by o ne radiologist who was not aware of the smoking histories of the patients. The radio logic c riterion

Nonsmokers 14 (34%)

21 (34%)

35(34%)

Total 41

61

102

for the diagnosb of divenicular disease was the presence of one o r more visible divcrticula.

RESULTS The prevalence of diverticu la r dis

ease inc reased with age (Figure 1 ). No d iverticula were found earlier than the fourth decade of life.

The sigmoid colon was the most common anatomic site for dive rtic ula (seen in 85°/ti of patients with diverticula). Other sites, in order of decreasing frequency, were descending (56%), transverse 02%). and ascending colon (32%).

Forty-one of the 102 patients had diverticula on barium ene ma. Sixtyseven had a positive smoking history. The percentage of patient~ with a smoking history was identical in patients with diverticula LO those without diverticula (Table I) .

The inc idence ofd iverticular disease

did not change with increasing numbers of cigarettes smoked (Tabli.' 2).

DISCUSSION T he data in the present !>Ludy me in

general agree ment with other st udics with respect to age d istrihu tion and anatomic site of diverricula (2,4, l 1 ).

The data failed to provide evidence that divert icular disease is associated with a history of smoking or the number of c igarettes smoked in a lifetime. T here are many difficultie/> that .irisc when undertaking experimental work into the effects of c igarette smoktng, wh ic h were well recognized tn .t study that reviewed c igarette smoking and inflammatory bowel disease (12). for example, there a re in excess of 3900 chemicals in c igarette smoke, and it is perhaps naive to propose an effect Jue to one component ( 13).

The endpoint chosen for this study was the absence or presence of diverticula. Barium enema 1s a widely used and sensi tive measure of diverticula (3, 14). No attempt was made to quantirate the number of diverticula nor the severity of symptoms. Thus it is poss1hle that the study was not suffic iently sensi tive, a lthN1gh t his is unlikely since the number of patiems with diverticu lnr disease d id nm increase wi th the number of cigarettes smoked.

The most evident source of error in this study is se lection bias, as only patients who needed a barium enema were included. However, most data on

TABLE 2 Relationship between cigarette pack-years and the incidence of diverticulosis

No. of Percentage with Pack-years patients diverticulosis

0 35 40

0-9 16 25 10-19 11 55 20-29 6 50 30-39 10 33 40-49 7 43 50-59 5 40 60-69 5 80 70-79 l 100 80-89 2 50 90-99 0 0

>100 4 0

194 CAN J GAST ROENTEROL VOL 4 No 5 Jl ILY/AU(,UST 1990

d1verticular Jbease have been collected in this way (4). The finding that 67% of patient~ in this study had imoke<l cigarettes in the ir lifetime is consistent with the current estimatetl rrevalence of 35% in the general population ( 15).

The physio lngic effects of nicotine

REFERENCES l. Mcm1che R, Williams CN. Diverri-

cular disease of thc col,in. Med C lin North Am 1988; 19:3683-9.

2 Connell AM. Pai hogencsi, of diver-ticular d1,ea;,c of rhc colon. Ad v ln1crn Med 1977;22:377-95.

l. Janower ML Divcmcul1ris and the contrnst enema. Am J RHdio l 1987; 149:861-2. (Lei t)

4. Mendcloff Al. Thoughts on the epidemiology of di vcrticub r di;,easc. Clm Gastroentcnil 1986; 15 :855-77.

i. Ficldmg JE. S mokmg: Health effect, and control. N Engl J Med 1985;3 I >:491-8.

6. Kikendall JW, Evaul J, Johnson LF. Effect of cigarette smoki ng on g;1stro1ntcst1nal physiology ,md no n-ncopla,tic digc,tive dbem,c. J C lm Gastroemcrol 1984:6:65-79. Weishmdt NW, I lug CC Jr, Schmiege SK Hass P. Effects of nici1tine .ind

have no t been studied extensively in man and thus it is poss ible that levels during smoking are not h igh enough to

st imulate rhe colon s ignificantly. There is controversy (6) about the interpretation of the tlata in unanesthetizeJ animals (8) in which rhe effect is explained by catec ho lamine re lease from

ryramine on contrac tile activity of the colon. Eur J Pharmacol 1970; 12:3 10-9.

8. Cari sa GM, RuJdon RW, Hug CC Jr, B,1:., P. Effects of nicotine on gastric antral and duodenal con tnictile ac-tivity in the dog. J Pharmacol Exp T licr 1970; 172:367-76.

9. Be ll JS, Go VL, DiMagno EP. The effec t of ,moking on the human inter-digestive motor complex. C lin Res 1980;28:763. (Abst)

10. Painter NS. The cause of divenicular d isease of che colon, its symptoms and it, comp I ications. Rev iew and hypothesis. J R Coll Surg Edin 1985; 30: 11 8-22.

11. Sardi A, Gokli A, S inger JA. Diver-ricu lard iscase of the cecum ,ind ascend-ing colon. A review ,,f 88 1 ca:,e,. A m Surg 1987;5 3:4 1-5.

12. Cope G F, Heatley RV, Kelleher J, Lee PN . C1gan.'tte :,moking and influm-marory bowel disease: A review. I lum

CAN j 0ASTROENTEROI VOi 4 Nl~ 5 JUtY/A UUUST 1990

Smoking and diverticular disease

peripheral ad renergic nerves and the adrenal medulla, causing relaxation of the proximal colon ( 16).

In summary, in patients undergoing barium enema, no ,is~ociation was demonstrated bet ween the presence of colon ic divenicula and a hisrory of c igarette smoking.

Tox1col 1987;6: 189-93. I>. ZariJze DG, Peto R, eJ ,. Tob,H:Cll, a

Majnr lmernaunnal I le.ilth Hazard. Proceeding, uf an mternatiomtl meet· mg o rganized hy the IARC and cn,pnn-,orcd by t he All-Union C,mcer Research Centre of the Academy of Medical Sciences of the USSR, Ml>,-cow, USSR, June 4-6, 1985. Lyon: In-ternat ional Agency for Research on Cancer, and New York: Oxford Univer-sity Press, 1986 (!ARC scient ific puhli-cat ions no 7 4).

14. A lmy T P, Howell DA. Divcrt icu lar dis-case o f the colon. N Engl J Med l 980;.302:324-3 1.

I 5. Bartlett L. S moking: We cannot afford the cost. O m Med Assoc J l 988;138:644-5.

[6. Carlson GM, Ruddon RW, I lug CC Jr, Schmiege SK, Bass r. Analysis nf the site of nicotine action on gastric amral and duodenal contractile activity. J Phanm1col ExpTher 1970;172:377-83.

195

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