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• W2785192112 abstract "Dissecting Diverticulosis Database DilemmasThis month’s issue of Clinical Gastroenterology and Hepatology offers 4 different studies that call into question some of the prior dogmas and myths regarding the pathophysiology and complications of diverticulosis, one of the most common digestive disorders. Diverticular disease accounts for the fifth most common digestive tract reason for ambulatory visits and is among the most common reasons for hospitalization, with 313,000 first-listed and 815,000 all-listed diagnoses and approximately $2.4 billion in annual direct costs in the United States.1Everhart J.E. Ruhl C.E. Burden of digestive diseases in the United States part II: lower gastrointestinal diseases.Gastroenterology. 2009; 136: 741-754Abstract Full Text Full Text PDF PubMed Scopus (292) Google Scholar The long-purported pathophysiology of diverticulosis and its primary complication, diverticulitis, related to low-fiber intake and increased intracolonic pressures recently has been called into question, with potential impacts related to mucosal inflammation and changes in the gut microbiome.2Peery A.F. Dellon E.S. Lund J. et al.Burden of gastrointestinal disease in the United States: 2012 update.Gastroenterology. 2012; 143 (1179–1187.e1-3)Abstract Full Text Full Text PDF PubMed Scopus (1382) Google ScholarMuch of the described epidemiology of diverticular disease preceded the expansion of colonoscopic examinations and relied on either postmortem estimates, surgical reports, or imaging studies; most of which were performed to evaluate complications such as diverticulitis and associated abscesses and perforations. In this issue of Clinical Gastroenterology and Hepatology, diverticulosis and its sequelae are approached by using 3 different databases that provide novel perspectives on the potential pathophysiologic underpinnings and scope of complications of diverticulosis.Two of the studies come from the administrative and clinical data from the Veterans Affairs Greater Los Angeles Healthcare System, derived from electronic medical records from 14 community clinics and 1 academic medical center. As would be anticipated from a Veterans Affairs system, the patients were more than 95% male, with a mean age of 62 years. Shahedi et al3Shahedi K. Fuller G. Bolus R. et al.Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy.Clin Gastroenterol Hepatol. 2013; 11: 1609-1613Abstract Full Text Full Text PDF PubMed Scopus (241) Google Scholar challenged the estimate of a 10% to 25% lifetime risk of diverticulitis for those with diverticulosis. The investigators collected data from 3992 patients who underwent colonoscopies between 1996 and 2011, of whom 2222 were reported to have diverticulosis at the baseline examination and were followed up for an average of 11 years. Patients with a pre-existing code for diverticulitis were excluded. Both liberal and strict diagnoses of diverticulitis were used and compared, and diverticulitis incidence rates were calculated. They identified 95 patients (4.3%) based on a liberal definition of diverticulitis, of whom 23 (1%) had rigorously defined events. The overall incidence of diverticulitis was 6 per 1000 patient-years, with a median time to event of 7 years. Patients who developed diverticulitis were significantly younger than the 2127 patients who did not, but there were no significant differences in race, ethnicity, or body mass index. Patients who received colonoscopies to investigate abdominal pain or defecatory symptoms did not have a greater risk of developing diverticulitis than patients who underwent colorectal screening examinations. In fact, the risk of developing a diverticulitis decreased by 2.4% per year of age at the time of diagnosis (Figure 1).In a second study, Cohen et al4Cohen E. Fuller G. Bolus R. et al.Increased risk for irritable bowel syndrome after acute diverticulitis.Clin Gastroenterol Hepatol. 2013; 11: 1614-1619Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar queried the same Veterans Affairs Greater Los Angeles Healthcare System database to explore the possibility of post-diverticulitis IBS based on the purported pathophysiologic overlap between diverticular disease and irritable bowel syndrome (IBS). A longitudinal study compared the risk of new IBS and functional bowel diseases in diverticulitis cases matched by age and sex vs controls who sought care on the same day. The overall incidence of IBS diagnoses in the 1105 predominantly male patients (mean age, 62 y) and chart-confirmed diverticulitis was only 2%. The risk of IBS compared with controls as measured by hazard rate was 4.7, while the hazard rate for any functional bowel disorder was 2.3. The authors argue biologic plausibility based on low-grade colonic inflammation that can “amplify visceral hypersensitivity, render the bowel more sensitive to negative effects of microbiota, and alter motility in IBS.”4Cohen E. Fuller G. Bolus R. et al.Increased risk for irritable bowel syndrome after acute diverticulitis.Clin Gastroenterol Hepatol. 2013; 11: 1614-1619Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar The authors also analogize the findings to postinfectious IBS although diagnoses of IBS are uncommon after the sixth decade (particularly in males).Maguire et al5Maguire L.H. Song M. Strate L.E. et al.Higher serum levels of vitamin D are associated with reduced risk of diverticulitis.Clin Gastroenterol Hepatol. 2013; 11: 1631-1635Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar used the Partners Healthcare Research Patient Data Registry from the integrated health care system in the greater Boston area, which provides care for more than 1.8 million patients. Based on an analysis of a national database of hospital admissions that observed seasonal variations in hospitalizations for diverticulitis,6Ricciardi R. Roberts P.L. Read T.E. et al.Cyclical increase in diverticulitis during the summer months.Arch Surg. 2011; 146: 319-323Crossref PubMed Scopus (29) Google Scholar the investigators hypothesized that vitamin D status might impact the pathogenesis of diverticulitis. They queried patients based on blood samples of vitamin D drawn before the diagnosis of diverticulitis. They found a significant negative correlation between vitamin D levels in patients with diverticulitis. These interesting findings need to be confirmed further given the limitations in the study design, including the absent comparison of vitamin D levels in patients who had a diagnosis of diverticulitis before vitamin D levels were obtained, the different indications for obtaining vitamin D levels in men and women, and the likelihood that low vitamin D levels would have been supplemented before the development of diverticulitis.Finally, Peery et al7Peery A.F. Sandler R.S. Ahnen D.J. et al.Constipation and a low-fiber diet are not associated with diverticulosis.Clin Gastroenterol Hepatol. 2013; 11: 1622-1627Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar analyzed data on 2813 enrollees, aged 45 to 75, from the vitamin D and Calcium Polyp Prevention study who were recruited from 11 study centers in North America during 2004 to 2008 and had a histologically verified colonic adenoma before study entry. A total of 539 patients who were documented to have diverticulosis at entry colonoscopy were compared with 1569 controls. Patients with a history of self-reported diverticulosis or diverticulitis were excluded. Participants had a systematic recording of intake history, including questions pertaining to diet, bowel habits, physical activity, smoking, medication use, and comorbidities, and body mass index was calculated. In contrast to the dogma that asymptomatic diverticulosis is associated with constipation and a low-fiber diet, participants with asymptomatic diverticulosis at colonoscopy in this study reported more frequent bowel movements, less frequent hard or lumpy stools, and no significant difference in mean dietary fiber intake than controls. Consistent with other reports, overweight participants and smokers also were found to have an increased risk of asymptomatic diverticulosis. Although it would have been nice to see a comparison between those with asymptomatic diverticulosis and (excluded) patients with a reported history of diverticular disease, the findings from patients with adenomas seem to buck the trend and challenge the hypothesis that low fiber and increased colonic pressures contribute to the genesis of diverticulosis.It will be of great interest to see if subsequent population-based studies of colonoscopically confirmed diverticulosis and diverticular disease provide further confirmation or refutation of these myth-breaking findings.See pages 1609, 1614, 1622, and 1631. Dissecting Diverticulosis Database DilemmasThis month’s issue of Clinical Gastroenterology and Hepatology offers 4 different studies that call into question some of the prior dogmas and myths regarding the pathophysiology and complications of diverticulosis, one of the most common digestive disorders. Diverticular disease accounts for the fifth most common digestive tract reason for ambulatory visits and is among the most common reasons for hospitalization, with 313,000 first-listed and 815,000 all-listed diagnoses and approximately $2.4 billion in annual direct costs in the United States.1Everhart J.E. Ruhl C.E. Burden of digestive diseases in the United States part II: lower gastrointestinal diseases.Gastroenterology. 2009; 136: 741-754Abstract Full Text Full Text PDF PubMed Scopus (292) Google Scholar The long-purported pathophysiology of diverticulosis and its primary complication, diverticulitis, related to low-fiber intake and increased intracolonic pressures recently has been called into question, with potential impacts related to mucosal inflammation and changes in the gut microbiome.2Peery A.F. Dellon E.S. Lund J. et al.Burden of gastrointestinal disease in the United States: 2012 update.Gastroenterology. 2012; 143 (1179–1187.e1-3)Abstract Full Text Full Text PDF PubMed Scopus (1382) Google ScholarMuch of the described epidemiology of diverticular disease preceded the expansion of colonoscopic examinations and relied on either postmortem estimates, surgical reports, or imaging studies; most of which were performed to evaluate complications such as diverticulitis and associated abscesses and perforations. In this issue of Clinical Gastroenterology and Hepatology, diverticulosis and its sequelae are approached by using 3 different databases that provide novel perspectives on the potential pathophysiologic underpinnings and scope of complications of diverticulosis.Two of the studies come from the administrative and clinical data from the Veterans Affairs Greater Los Angeles Healthcare System, derived from electronic medical records from 14 community clinics and 1 academic medical center. As would be anticipated from a Veterans Affairs system, the patients were more than 95% male, with a mean age of 62 years. Shahedi et al3Shahedi K. Fuller G. Bolus R. et al.Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy.Clin Gastroenterol Hepatol. 2013; 11: 1609-1613Abstract Full Text Full Text PDF PubMed Scopus (241) Google Scholar challenged the estimate of a 10% to 25% lifetime risk of diverticulitis for those with diverticulosis. The investigators collected data from 3992 patients who underwent colonoscopies between 1996 and 2011, of whom 2222 were reported to have diverticulosis at the baseline examination and were followed up for an average of 11 years. Patients with a pre-existing code for diverticulitis were excluded. Both liberal and strict diagnoses of diverticulitis were used and compared, and diverticulitis incidence rates were calculated. They identified 95 patients (4.3%) based on a liberal definition of diverticulitis, of whom 23 (1%) had rigorously defined events. The overall incidence of diverticulitis was 6 per 1000 patient-years, with a median time to event of 7 years. Patients who developed diverticulitis were significantly younger than the 2127 patients who did not, but there were no significant differences in race, ethnicity, or body mass index. Patients who received colonoscopies to investigate abdominal pain or defecatory symptoms did not have a greater risk of developing diverticulitis than patients who underwent colorectal screening examinations. In fact, the risk of developing a diverticulitis decreased by 2.4% per year of age at the time of diagnosis (Figure 1).In a second study, Cohen et al4Cohen E. Fuller G. Bolus R. et al.Increased risk for irritable bowel syndrome after acute diverticulitis.Clin Gastroenterol Hepatol. 2013; 11: 1614-1619Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar queried the same Veterans Affairs Greater Los Angeles Healthcare System database to explore the possibility of post-diverticulitis IBS based on the purported pathophysiologic overlap between diverticular disease and irritable bowel syndrome (IBS). A longitudinal study compared the risk of new IBS and functional bowel diseases in diverticulitis cases matched by age and sex vs controls who sought care on the same day. The overall incidence of IBS diagnoses in the 1105 predominantly male patients (mean age, 62 y) and chart-confirmed diverticulitis was only 2%. The risk of IBS compared with controls as measured by hazard rate was 4.7, while the hazard rate for any functional bowel disorder was 2.3. The authors argue biologic plausibility based on low-grade colonic inflammation that can “amplify visceral hypersensitivity, render the bowel more sensitive to negative effects of microbiota, and alter motility in IBS.”4Cohen E. Fuller G. Bolus R. et al.Increased risk for irritable bowel syndrome after acute diverticulitis.Clin Gastroenterol Hepatol. 2013; 11: 1614-1619Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar The authors also analogize the findings to postinfectious IBS although diagnoses of IBS are uncommon after the sixth decade (particularly in males).Maguire et al5Maguire L.H. Song M. Strate L.E. et al.Higher serum levels of vitamin D are associated with reduced risk of diverticulitis.Clin Gastroenterol Hepatol. 2013; 11: 1631-1635Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar used the Partners Healthcare Research Patient Data Registry from the integrated health care system in the greater Boston area, which provides care for more than 1.8 million patients. Based on an analysis of a national database of hospital admissions that observed seasonal variations in hospitalizations for diverticulitis,6Ricciardi R. Roberts P.L. Read T.E. et al.Cyclical increase in diverticulitis during the summer months.Arch Surg. 2011; 146: 319-323Crossref PubMed Scopus (29) Google Scholar the investigators hypothesized that vitamin D status might impact the pathogenesis of diverticulitis. They queried patients based on blood samples of vitamin D drawn before the diagnosis of diverticulitis. They found a significant negative correlation between vitamin D levels in patients with diverticulitis. These interesting findings need to be confirmed further given the limitations in the study design, including the absent comparison of vitamin D levels in patients who had a diagnosis of diverticulitis before vitamin D levels were obtained, the different indications for obtaining vitamin D levels in men and women, and the likelihood that low vitamin D levels would have been supplemented before the development of diverticulitis.Finally, Peery et al7Peery A.F. Sandler R.S. Ahnen D.J. et al.Constipation and a low-fiber diet are not associated with diverticulosis.Clin Gastroenterol Hepatol. 2013; 11: 1622-1627Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar analyzed data on 2813 enrollees, aged 45 to 75, from the vitamin D and Calcium Polyp Prevention study who were recruited from 11 study centers in North America during 2004 to 2008 and had a histologically verified colonic adenoma before study entry. A total of 539 patients who were documented to have diverticulosis at entry colonoscopy were compared with 1569 controls. Patients with a history of self-reported diverticulosis or diverticulitis were excluded. Participants had a systematic recording of intake history, including questions pertaining to diet, bowel habits, physical activity, smoking, medication use, and comorbidities, and body mass index was calculated. In contrast to the dogma that asymptomatic diverticulosis is associated with constipation and a low-fiber diet, participants with asymptomatic diverticulosis at colonoscopy in this study reported more frequent bowel movements, less frequent hard or lumpy stools, and no significant difference in mean dietary fiber intake than controls. Consistent with other reports, overweight participants and smokers also were found to have an increased risk of asymptomatic diverticulosis. Although it would have been nice to see a comparison between those with asymptomatic diverticulosis and (excluded) patients with a reported history of diverticular disease, the findings from patients with adenomas seem to buck the trend and challenge the hypothesis that low fiber and increased colonic pressures contribute to the genesis of diverticulosis.It will be of great interest to see if subsequent population-based studies of colonoscopically confirmed diverticulosis and diverticular disease provide further confirmation or refutation of these myth-breaking findings.See pages 1609, 1614, 1622, and 1631. This month’s issue of Clinical Gastroenterology and Hepatology offers 4 different studies that call into question some of the prior dogmas and myths regarding the pathophysiology and complications of diverticulosis, one of the most common digestive disorders. Diverticular disease accounts for the fifth most common digestive tract reason for ambulatory visits and is among the most common reasons for hospitalization, with 313,000 first-listed and 815,000 all-listed diagnoses and approximately $2.4 billion in annual direct costs in the United States.1Everhart J.E. Ruhl C.E. Burden of digestive diseases in the United States part II: lower gastrointestinal diseases.Gastroenterology. 2009; 136: 741-754Abstract Full Text Full Text PDF PubMed Scopus (292) Google Scholar The long-purported pathophysiology of diverticulosis and its primary complication, diverticulitis, related to low-fiber intake and increased intracolonic pressures recently has been called into question, with potential impacts related to mucosal inflammation and changes in the gut microbiome.2Peery A.F. Dellon E.S. Lund J. et al.Burden of gastrointestinal disease in the United States: 2012 update.Gastroenterology. 2012; 143 (1179–1187.e1-3)Abstract Full Text Full Text PDF PubMed Scopus (1382) Google Scholar Much of the described epidemiology of diverticular disease preceded the expansion of colonoscopic examinations and relied on either postmortem estimates, surgical reports, or imaging studies; most of which were performed to evaluate complications such as diverticulitis and associated abscesses and perforations. In this issue of Clinical Gastroenterology and Hepatology, diverticulosis and its sequelae are approached by using 3 different databases that provide novel perspectives on the potential pathophysiologic underpinnings and scope of complications of diverticulosis. Two of the studies come from the administrative and clinical data from the Veterans Affairs Greater Los Angeles Healthcare System, derived from electronic medical records from 14 community clinics and 1 academic medical center. As would be anticipated from a Veterans Affairs system, the patients were more than 95% male, with a mean age of 62 years. Shahedi et al3Shahedi K. Fuller G. Bolus R. et al.Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy.Clin Gastroenterol Hepatol. 2013; 11: 1609-1613Abstract Full Text Full Text PDF PubMed Scopus (241) Google Scholar challenged the estimate of a 10% to 25% lifetime risk of diverticulitis for those with diverticulosis. The investigators collected data from 3992 patients who underwent colonoscopies between 1996 and 2011, of whom 2222 were reported to have diverticulosis at the baseline examination and were followed up for an average of 11 years. Patients with a pre-existing code for diverticulitis were excluded. Both liberal and strict diagnoses of diverticulitis were used and compared, and diverticulitis incidence rates were calculated. They identified 95 patients (4.3%) based on a liberal definition of diverticulitis, of whom 23 (1%) had rigorously defined events. The overall incidence of diverticulitis was 6 per 1000 patient-years, with a median time to event of 7 years. Patients who developed diverticulitis were significantly younger than the 2127 patients who did not, but there were no significant differences in race, ethnicity, or body mass index. Patients who received colonoscopies to investigate abdominal pain or defecatory symptoms did not have a greater risk of developing diverticulitis than patients who underwent colorectal screening examinations. In fact, the risk of developing a diverticulitis decreased by 2.4% per year of age at the time of diagnosis (Figure 1). In a second study, Cohen et al4Cohen E. Fuller G. Bolus R. et al.Increased risk for irritable bowel syndrome after acute diverticulitis.Clin Gastroenterol Hepatol. 2013; 11: 1614-1619Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar queried the same Veterans Affairs Greater Los Angeles Healthcare System database to explore the possibility of post-diverticulitis IBS based on the purported pathophysiologic overlap between diverticular disease and irritable bowel syndrome (IBS). A longitudinal study compared the risk of new IBS and functional bowel diseases in diverticulitis cases matched by age and sex vs controls who sought care on the same day. The overall incidence of IBS diagnoses in the 1105 predominantly male patients (mean age, 62 y) and chart-confirmed diverticulitis was only 2%. The risk of IBS compared with controls as measured by hazard rate was 4.7, while the hazard rate for any functional bowel disorder was 2.3. The authors argue biologic plausibility based on low-grade colonic inflammation that can “amplify visceral hypersensitivity, render the bowel more sensitive to negative effects of microbiota, and alter motility in IBS.”4Cohen E. Fuller G. Bolus R. et al.Increased risk for irritable bowel syndrome after acute diverticulitis.Clin Gastroenterol Hepatol. 2013; 11: 1614-1619Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar The authors also analogize the findings to postinfectious IBS although diagnoses of IBS are uncommon after the sixth decade (particularly in males). Maguire et al5Maguire L.H. Song M. Strate L.E. et al.Higher serum levels of vitamin D are associated with reduced risk of diverticulitis.Clin Gastroenterol Hepatol. 2013; 11: 1631-1635Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar used the Partners Healthcare Research Patient Data Registry from the integrated health care system in the greater Boston area, which provides care for more than 1.8 million patients. Based on an analysis of a national database of hospital admissions that observed seasonal variations in hospitalizations for diverticulitis,6Ricciardi R. Roberts P.L. Read T.E. et al.Cyclical increase in diverticulitis during the summer months.Arch Surg. 2011; 146: 319-323Crossref PubMed Scopus (29) Google Scholar the investigators hypothesized that vitamin D status might impact the pathogenesis of diverticulitis. They queried patients based on blood samples of vitamin D drawn before the diagnosis of diverticulitis. They found a significant negative correlation between vitamin D levels in patients with diverticulitis. These interesting findings need to be confirmed further given the limitations in the study design, including the absent comparison of vitamin D levels in patients who had a diagnosis of diverticulitis before vitamin D levels were obtained, the different indications for obtaining vitamin D levels in men and women, and the likelihood that low vitamin D levels would have been supplemented before the development of diverticulitis. Finally, Peery et al7Peery A.F. Sandler R.S. Ahnen D.J. et al.Constipation and a low-fiber diet are not associated with diverticulosis.Clin Gastroenterol Hepatol. 2013; 11: 1622-1627Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar analyzed data on 2813 enrollees, aged 45 to 75, from the vitamin D and Calcium Polyp Prevention study who were recruited from 11 study centers in North America during 2004 to 2008 and had a histologically verified colonic adenoma before study entry. A total of 539 patients who were documented to have diverticulosis at entry colonoscopy were compared with 1569 controls. Patients with a history of self-reported diverticulosis or diverticulitis were excluded. Participants had a systematic recording of intake history, including questions pertaining to diet, bowel habits, physical activity, smoking, medication use, and comorbidities, and body mass index was calculated. In contrast to the dogma that asymptomatic diverticulosis is associated with constipation and a low-fiber diet, participants with asymptomatic diverticulosis at colonoscopy in this study reported more frequent bowel movements, less frequent hard or lumpy stools, and no significant difference in mean dietary fiber intake than controls. Consistent with other reports, overweight participants and smokers also were found to have an increased risk of asymptomatic diverticulosis. Although it would have been nice to see a comparison between those with asymptomatic diverticulosis and (excluded) patients with a reported history of diverticular disease, the findings from patients with adenomas seem to buck the trend and challenge the hypothesis that low fiber and increased colonic pressures contribute to the genesis of diverticulosis. It will be of great interest to see if subsequent population-based studies of colonoscopically confirmed diverticulosis and diverticular disease provide further confirmation or refutation of these myth-breaking findings. See pages 1609, 1614, 1622, and 1631. Increased Risk for Irritable Bowel Syndrome After Acute DiverticulitisClinical Gastroenterology and HepatologyVol. 11Issue 12PreviewIndividuals with diverticulosis frequently also have irritable bowel syndrome (IBS), but there are no longitudinal data to associate acute diverticulitis with subsequent IBS, functional bowel disorders, or related emotional distress. In patients with postinfectious IBS, gastrointestinal disorders cause long-term symptoms, so we investigated whether diverticulitis might lead to IBS. We compared the incidence of IBS and functional bowel and related affective disorders among patients with diverticulitis. Full-Text PDF Constipation and a Low-Fiber Diet Are Not Associated With DiverticulosisClinical Gastroenterology and HepatologyVol. 11Issue 12PreviewAsymptomatic diverticulosis is commonly attributed to constipation caused by a low-fiber diet, although evidence for this mechanism is limited. We examined the associations between constipation and low dietary fiber intake with risk of asymptomatic diverticulosis. Full-Text PDF Higher Serum Levels of Vitamin D Are Associated With a Reduced Risk of DiverticulitisClinical Gastroenterology and HepatologyVol. 11Issue 12PreviewRecent studies have shown geographic and seasonal variations in hospital admissions for diverticulitis. Because this variation parallels differences in ultraviolet light exposure, the most important contributor to vitamin D status, we examined the association of prediagnostic serum levels of vitamin D with diverticulitis. Full-Text PDF Long-term Risk of Acute Diverticulitis Among Patients With Incidental Diverticulosis Found During ColonoscopyClinical Gastroenterology and HepatologyVol. 11Issue 12PreviewColonic diverticulosis is the most common finding during routine colonoscopy, and patients often question the significance of these lesions. Guidelines state that these patients have a 10% to 25% lifetime risk of developing acute diverticulitis. However, this value was determined based on limited data, collected before population-based colonoscopy, so the true number of cases of diverticulosis was not known. We measured the long-term risk of acute diverticulitis among patients with confirmed diverticulosis discovered incidentally on colonoscopy. Full-Text PDF" @default.
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