Diverticular disease (diverticulosis) of the colon is a morphological pathological process, distinctive feature of which is the presence of a saccular protrusions of the wall of the colon (diverticula).
Diverticula are localized in different parts of the colon with varying degrees of frequency. Isolated in the sigmoid colon, diverticula occur in 30% of patients, in descending colon — in 13%, most commonly diverticulitis take both of these division — 38 % of cases. In the proximal segments of the colon diverticulosis is less common in the transverse colon — in 5% of patients, rising 6 % in the caecum — 3% of patients. A total lesion of the colon is also quite rare — 5% of cases.
Diverticula are a manifestation of various pathological conditions, among which the leading role have degenerative changes in the muscular wall of the colon, discoordination her motor skills, innate or acquired weakness of the connective tissue, vascular changes in the intestinal wall. Dystrophy muscular apparatus of the intestine occurs, in particular, of elderly persons as a manifestation of common degenerative processes of atherosclerosis with ischemic disorders. In addition, some patients have a congenital weakness of the connective tissue associated with impaired synthesis of collagen, which is manifested in the formation of gruzevich protrusions of the abdominal wall, diaphragm, etc. the appearance of diverticula in persons of middle age group plays an important role discoordination motility of the colon. Amid spasm, especially of the left departments of the colon, excessive internal intestinal pressure leads to a discrepancy between muscle fibers and the formation of diverticula even in the absence of source degeneration of the muscular layer.
Modern ideas about the development of diverticular disease include vascular factor: when spasm of the muscle layer occurs compression vnutrismennyh vessels with disruption of the microcirculation — ischemia and slowing of the venous outflow. All the above leads to dystrophic changes and expansion of the perivascular spaces, which become the mouth of the diverticula. Thus, the pouch is the ultimate manifestation of the disease of the intestinal wall, pulping the circular muscle layer atrophy and enhancing it in the “weak” field (in the zone of the perforating vessels).
There are certain anatomic prerequisites for the development of diverticula in the colon. These include:
- the formation of an outer muscular layer in the form of three bands (plants), which relaxes the gut to internal and external influences;
- the nature of the vascular architectonics of the presence of arteries and veins the vessels perforating the muscular frame, resulting in the intestinal wall form places of least resistance;
- the presence of gaustr, which can generate high internal intestinal pressure.
In the etiopathogenesis of diverticular disease important role belongs to the change of diet and lifestyle in the last 100 years in industrialized countries, which confirms the absence of diverticulosis in rural areas of Africa and South-East Asia. The distribution model and diverticulosis in the background of industrialization can serve the residents of North America, where the proportion of fiber in the diet since the end of the XIX century. decreased by 10 times; diverticulosis of the colon here almost with the same frequency observed among white and black patients.
Thus, diverticulosis of the colon is polietiologic disease in which play the role of both local and systemic factors, as a result of which the intestinal wall becomes characteristic changes.
Depending on the clinical form of diverticulosis observed a variety of intestinal symptoms. In accordance with the standards of the Society of colorectal surgeons, USA (2000), diverticular disease is considered as a complex of clinical signs and symptoms associated with diverticulosis, ranging from minor intensity of abdominal pain to complications of diverticulosis.
A significant part of individuals diverticulosis occurs without any symptoms and is detected incidentally during the examination of the intestines for various other reasons.
Clinically evident uncomplicated diverticulosis manifested mainly pain of various character and intensity, and violation of the stool.
The pain is localized more often in the left iliac region and left mesogastric — in the projection of the sigmoid colon and is spastic in nature, increasing as the filling of the colon stool. After defecation pain syndrome usually decreases. Patients notes in between these spasms of dull aching pain in the same departments. On palpation of the abdomen can not determine the localization of the disease outbreak, indicating the absence of organic causes of pain, which is associated in this case with the discoordination of the motility of the colon. Duration of pain varies from several days and weeks to constant pain for a long time.
Violation of the stool is usually manifested in the form of constipation. In addition, patients often complain of a feeling of incomplete emptying of the bowel and bloating. Some patients have alternating constipation and the appearance of liquid stool.
For clinically significant diverticulosis (diverticular disease) are not always harmless as it seems to most gastroenterologists. Frequent bouts of abdominal pain, persistent violations of defecation sometimes cause these patients to gradual loss of ability to work. They become permanent patients in the gastroenterology or Coloproctology rooms where they try, unsuccessfully treated with various means.
In our country, the accepted clinical classification of diverticular disease, which allows to assess the condition, prognosis, and the main thing — to choose the right individual treatment tactics.
1. Asymptomatic diverticulosis.
2. Diverticulosis clinical manifestations.
3. Complicated diverticulosis:
- ekologichesky infiltration;
- perforation of the diverticulum;
- intestinal fistula;
- intestinal bleeding.
The first group consists of patients with absence of bowel symptoms, diverticula find them when searching for other diseases. Clinically evident diverticulosis is often accompanied by manifestations of spasm of the intestinal wall, a violation of the digestive processes and balance the intestinal microflora, which requires systemic therapy. Complications of diverticulosis have basically encounter practical surgeons in the delivery of emergency assistance.
Clinical symptoms varies greatly with the development of complications of diverticular disease.
Diverticulitis (inflammation of diverticulum) is the most frequent complication of diverticular disease. Inflammation of the diverticulum develops as a result of stagnation of fecal matter in the diverticula on the background of the degeneration of the bowel wall, loss of the barrier properties of the epithelium, the action of pathogenic intestinal microflora. Due to the congestion and edema of the diverticulum with a portion adjacent the wall increases in size, serosa of the intestine is covered with fibrin, and inflammatory changes can be expressed so that decreases the internal lumen of the affected segment of the colon, disturbed passage of intestinal contents.
Diverticulitis is accompanied by constant pain in the abdomen, fever up to subfebrile values. The accession of inflammation of the mesentery of the sigmoid colon, the greater omentum, the surrounding organs forms Ekologichesky infiltration, which is palpated in the form of an inflammatory tumor of the left half of the abdomen.
The development of inflammation in the abdomen, violation of the integrity of the wall of the diverticulum lead to the formation ekologicheskogo infiltration or abscess. Inflammatory tumor may be located in the left iliac region, above the pubis, in lateral projection of the left channel and mimic a malignant process. The formation of an abscess alters the intensity and nature of pain, there is a growing fever, often takes the hectic swings in the evening hours. On the background of infiltration occurs narrowing of the lumen of the intestine, leading to constipation, bloating, nausea, vomiting.
Perforation of the diverticulum into the free abdominal cavity leads to the development of peritonitis, and in the mesentery of the sigmoid colon — retroperitoneal phlegmon. If the abscess is opened on the skin of the abdominal wall or surrounding the hollow body, the outcome of suppuration are internal and external fistula connecting the lumen of the colon, skin, bladder, and rarely the small bowel or the vagina. Fistulas do not tend to spontaneous closure and require surgical treatment.
Signs of the presence of blood in the feces are present in 20-30 % of patients with diverticulosis, however, intestinal bleeding in diverticulosis rarely is profuse in nature. In severe atrophy of the mucous membrane of trauma of hard stool can cause damage to the vessel and the loss of significant amounts of blood during defecation and separately from the stool. The stool of such patients is commonly described as “raspberry jelly” blood curdle, but the process of decomposition had not yet begun.
Careful questioning of the patient provides important information for accurate diagnosis. Complaints of abdominal discomfort, pain from spasticity, and recurrent constipation, and a history of episodes of fever associated with intense pain in the left iliac region, indicate the possibility of diverticular disease.
Palpation of the abdomen allows you to identify the painful area. Usually it is the left iliac region and left nazogastralny area. In the case of diverticulitis, you can find painful infiltrate with indistinct contours, also occupying specified anatomical area. The symptoms of peritoneal irritation indicate a more dangerous complications: perforation of the diverticulum, precisecolor breakthrough abscess into the abdominal cavity. With an increase of the phenomena of violation of intestinal permeability can be detected swelling, asymmetry of the abdomen, percussion determined the increased colon and loops of the small intestine, the peristalsis is strengthened. An important clinical sign of violation of integrity of a hollow organ is the disappearance of percussion hepatic dullness.
The most informative method of detection of diverticulosis of the colon is examination of the colon using barium enema (barium enema). In uncomplicated diverticulosis, the intestinal wall is of irregular contour and forms a saccular protrusions along its outline, having narrowed the base (the mouth). The size of these protrusions range from 0.2—0.3 to 1-2 cm, often in the sigmoid and descending colon intestines. For the detection of diverticula sometimes necessary images in the lateral projection. Pay attention to the tone of the intestine, the depth maggioncalda folds, as well as the extensibility and elasticity of the intestinal wall. Barium enema allows to detect the removability of the parts of the colon or, alternatively, their fixing precisecolor as a result of the inflammatory process.
In addition, the x-ray method allows to detect the narrowing of the lumen of the sigmoid colon in case of infiltration, as well as complete contrast fistulous passages (fistulografiya).
There are three types of morpho-functional changes detected radiologically diverticular disease.
The first type is the lumen of the intestine 3.5-4.0 cm, hypertonicity is not expressed, mercaptamine folds are smoothed, elasticity of the wall preserved.
The second type — clearance of 2.5—3.5 cm, Australia drawing strain, a high mercaptamine folds, elasticity saved.
The third type is a clearance less than 2.5 cm, persistent hypertonicity, haustration chaotic, sawtooth contour, elasticity is reduced, the gut is fixed.
The third type of morphological and functional changes is least favorable in the predictive relation, it is to be expected of such complications of disease, such as diverticulitis, precisely infiltration, abscess formation or perforation.
No less informative method of detection of diverticulosis is colonoscopy, which in addition to determining the presence of diverticula allows you to specify the length of the inflammatory changes in the lumen of the intestine, the location of diverticula and the condition of their mucosa. It must be remembered that colonoscopy on the background of diverticulitis can lead to colon perforation and should be applied between the clinic and the data of irrigoscopy.
Differential diagnosis. To confirm the presence of the patient diverticular disease — often a difficult task, especially if the first manifestation of the disease was caused by inflammatory complications.
The study of cases of complications of diverticulosis in the Department of urgent surgery indicates that for the admission the clinical picture in these patients can be taken as a manifestation of various diseases. Accurate diagnosis of diverticulitis for the initial examination is set, as a rule, only a small percentage of patients. In the remaining patients fall under suspicion other diseases associated not only with pathology of the colon (tumor of the colon, peritonitis of unknown etiology, acute appendicitis, adnexitis, renal colic.
Diverticulitis and cancer differencesbut on the following criteria: in the malignant process longer history, the gradual development of the disease, often present in small symptoms of cancer, anemia. Barium enema reveals the presence of a long stricture in the area of the diverticula with a fairly clear boundaries, for cancer is more common suprastenotic the expansion of the colon associated with a long-emerging disorders of intestinal permeability. Endoscopic examination in cases of suspected diverticulitis must be made with caution due to the danger of perforation, however, a visual inspection allows you to install the inflammatory changes of the mucosa distal to the constriction, which is more typical for diverticulosis. It is crucial to the detection in biopsy of the colon tumor tissue, although its absence is sometimes not possible to rule out the presence of malignant lesions. In some cases, can be used ultrasonic colonoscopy. Often, however, the final diagnosis is possible only after morphological study of the remote during the operation the affected area of the colon.
Crohn’s disease may also have similar clinical picture of diverticulitis. For the correct diagnosis helps the medical history is characteristic of Crohn’s disease, diarrhea, mucus and blood in feces and rectal examination and sigmoidoscopy. In the study of the rectum exhibit inflammatory lesions, longitudinal ulcers, fissures and traces of perianal lesions common in Crohn’s disease of the colon.
To differentiate from diverticulosis ischemic colitis help the nature of the pain syndrome, a long history of pain and lower its intensity, frequent urge to defecate, the localization process in the left flexure of the colon.
In all cases, any local infiltrative process in the context of diverticula in the colon, be sure to perform a morphological study. In case of impossibility of such a study, surgical treatment, since none of the differential criteria is not absolute to the exclusion of the malignant process. It should be remembered that colon cancer on a background of diverticular disease occurs 2-3 times more often than in those without diverticula in the colon.
Depending on the characteristics of the etiology, pathogenesis and stage of disease choose appropriate approaches to the treatment of diverticular disease.
Diverticulosis asymptomatic, accidentally discovered during an examination requires special care. You must specify the patient for the presence of risk of complications of the disease. Prevention in this case can be considered the regulation of stool to avoid constipation primarily through diet. The tendency to constipation is prescribed laxatives, it is better oil.
In the selection of treatment clinically significant and complicated types diverticulosis need to establish the etiology of a condition in a specific patient, namely: whether there has been a development of diverticula on the background of degenerative changes of the intestinal wall, systemic pathology of the connective tissue or incoordination of intestinal motility.
If constipation associated with atony and degeneration of the intestinal wall in older patients, it is also necessary the use of oil laxatives, combined with a diet rich in fiber and fluids (1500 ml of fluid per day).
If prevail symptoms incoordination motility of the colon in patients of middle age, is assigned a set of measures aimed at the systemic treatment of this condition. It includes means of normalizing peristalsis and prevents spastic contractions of the intestinal wall, prokinetics. Violation of processes of digestion corrected by the appointment of enzyme preparations. Important correction developing dysbacteriosis on the background of chronic violations of the emptying of the colon, which is detected by analysis of the intestinal microflora and corrected by the appointment of eubiotic. It is also necessary to pay attention of the patient on the need for a balanced diet: your diet should contain a sufficient amount of ballast substances, and meals take place at a set time and in sufficient volume.
Inflammatory complications (diverticulitis, precisely infiltration) tactics of treatment varies. Patient hospitalitynet. When moderately expressed phenomena of intoxication appoint oily laxatives (mineral oil) to soften the stool, uncindery a diet with restriction of fiber. Shown broad spectrum antibiotics, antispasmodics. To exclude perforation of the colon conduct x-ray examination of the abdomen with the patient standing, dynamic ultrasonic inspection of infiltration. It is preferable to perform the operation while calming inflammation. Complications in this case make up 3-6% versus 20% in interventions on the height of the inflammation. If, however, on the background of therapy the patient’s condition worsens, there are growing signs of intoxication, appear ultrasound signs of abecedarian or clinical manifestations of peritonitis, used more active surgical tactics — opening the abscess with the formation of the proximal colostomy, resection of the affected segment also with the imposition of a temporary stoma.
Bleeding in 80% of cases it is possible to stop the conservative measures (gemostatiki, infusion therapy, bed rest, barium enema, which in some cases has a healing effect). The ineffectiveness of these measures is the operation — removal of segment of colon with the bleeding vessel (usually a left hemicolectomy).
In General, indications for surgery can be divided into absolute and relative. Absolute indications include perforation, massive hemorrhage, and the ineffectiveness of the conservative treatment of diverticulitis (increase in toxicity, abscess infiltration), intestinal obstruction, inability to rule out cancer.
Relative indications for surgery: recurrent intestinal bleeding, chronically recurrent diverticulitis, fistulas of the colon, infiltration, the lack of effect in the conservative treatment of symptomatic diverticular disease.
The volume of surgery for diverticular disease depends on the nature of the disease and its complications. The most commonly used resection of the diverticula is the most affected segment of the colon or zone of complications (perforation, infiltration, fistula, etc.). There are various types of resections of the colon or sensomotory. The choice of a particular surgical intervention is influenced by the following factors: the prevalence of diverticula, the presence of inflammatory changes (surgical treatment in this case is performed in several stages), the age and General condition of the patient. The presence of inflammatory complications and high risk of insolvency of the anastomosis due to trophic changes in the intestinal wall form a large group of patients who have had to abandon a primary anastomosis, and to divide the surgical treatment into several stages. In particular, it is necessary for violation of intestinal permeability, diverticulitis, perifocal inflammation, intestinal fistula, severe somatic pathology.
Currently, along with resection of the colon with symptomatic diverticulosis also used an operation that was designed to eliminate the pathogenetic mechanisms that play a role in the development of diverticular disease. The indications are pain, persistent hypertonicity, elderly age, comorbidities that increase the risk of resection. The essence of the operation consists in dissection or excision of the serous-muscular flap at the mess of the sigmoid colon, which helps to reduce the tone of the intestinal wall and the normalization of the intraluminal pressure. Interestingly, the dynamic observation of patients after these operations demonstrates not only the disappearance of clinical symptoms, but also about involution of diverticula themselves for several years.
Favorable with timely prevention of complications, as well as an active therapeutic tactics in case of clinically significant diverticulosis. The rapid development of purulent complications, the emergence of signs of acute abdomen, make the prognosis more doubtful, as with other acute surgical diseases of the abdominal cavity purulent character.