Diverticulitis

Description:

The diverticulitis — a diverticulum inflammation — belongs to the most frequent complications of this disease. The diverticulitis occurs at 10 — 25% of patients with diverticulums of a large intestine. The diverticulitis can lead to perforation of a diverticulum. Microperforation can remain localized and lead to a perikolit, formation of infiltrate, abscess or fistula. According to Hinchey E classification. J. and соавт. (1978) perforation can lead to a local perikolit and abscess — the 1st stage; to the remote abscess (retroperitoneal or pelvic) — the 2nd stage; to diffuse peritonitis, owing to distribution of a perikolit or pelvic abscess — the 3rd stage; to fecal peritonitis owing to perforation of a diverticulum in a free abdominal cavity - the 4th stage.

Diverticulitis reasons:

Development of a diverticulitis happens most often because of a delay in protrusion of the food remains, formations of fecal stones and joining of the infectious agent. Inflammatory process can be limited only to the site of a diverticulum or extend to the next bodies and fabrics therefore interintestinal abscess or peritonitis forms.

Diverticulitis symptoms:

Patients with an acute diverticulitis complain of sudden pain in the left ileal area. Patients with a dolichosigma can have a pain in paraumbilical area or even on the right. At right-hand localization of diverticulums pain also arises on the right. Pain can be irregular or constant, and often contacts a diarrhea or a lock. Release of blood (gematosheziya) happens to a stake seldom, anorexia and nausea sometimes develops. At a stomach palpation the localized irritation of a peritoneum in the left lower quadrant usually comes to light where sometimes to be defined infiltrate of oblong shape. Intestinal noise are weakened. At a rectum research a finger sometimes it is possible to find the infiltrate testimonial of formation of abscess in a small basin. At most of patients body temperature is increased, at 45% the leukocytosis is defined.
The diagnosis can be established at a kolonoskopiya, X-ray inspection with use of an opaque enema and ultrasonography. Contrast KT is especially effective. Diagnostic criteria of a diverticulitis are intraparietal cavities (abscess) and fistulas. Sensitivity of this method reaches 69 — 95%, and specificity — 75 — 100%. High level of diagnosis can be provided also with use of an ultrasonografiya. Hypoechoic expansion of a wall of a gut, existence of a diverticulum or the abscess surrounded with hyper echoic structures of the inflamed gut wall are characteristic signs of a diverticulitis at ultrasonography. According to Zielke A. and соавт., (1997) sensitivity of this method makes 84 — 98% and specificity — 80 — 98%. The endoscopic research is usually contraindicated at an acute diverticulitis because of risk of perforation or the tool or air filled a gut. Therefore the kolonoskopiya can be shown only in case of not clear diagnosis. The research should be conducted with the minimum insufflation of air, carefully. In case of a successful endoscopic research it is possible to exclude other inflammatory diseases of a large intestine and a tumor.
The differential diagnosis is carried out with an acute appendicitis, a disease Krone, a tumor of a large intestine, ischemic and pseudomembranous colitis, urological and gynecologic diseases. Pseudomembranous colitis is connected with use of antibiotics. Its exact diagnosis is based on definition in Calais of toxin. The oothecoma with abscess is diagnosed by means of ultrasonography of a small pelvis or transvaginal ultrasonography. Apply the test for pregnancy and an ultrasonic method to diagnosis of an extrauterine pregnancy.

Complications:

Abscess. Abscess should be suspected at all a sick diverticulitis with high fever and a leukocytosis, despite adequate antibacterial therapy. Small abscesses it is possible to try to continue to treat conservatively, big abscesses demand surgical treatment.
Fistulas. Fistulas can get into a bladder and a uterus. The only method of treatment is the resection of body with closing of an anastomosis.
Impassability. Acute impassability at a diverticulitis develops usually in the course of conservative treatment. At patients with a recurrent diverticulitis narrowing of a gut and chronic impassability can develop. In this case the differential diagnosis with a tumor and inflammatory diseases of other etiology is necessary. Treatment of intestinal impassability — surgical.
Bleeding. On Zuccaro G observations. (1998) at 10 — 15% of patients with a gematosheziya the bleeding point is in an upper part of digestive tract. Diverticulums and vascular ectasia are the reason of the majority of bleedings of lower parts of digestive tract. Serious bleeding occurs at 3 — 5% of patients with a divertuculosis. More often diverticulums of the ascending and blind guts are complicated by bleeding. From diverticulums nonsteroid antiinflammatory drugs can provoke bleeding. Therefore the divertuculosis should be considered a contraindication for purpose of these drugs.
Bleeding from diverticulums arterial. The inflammation is probably not a provocative factor. Bleeding usually begins suddenly, without the previous pains. There is a clot or a large number red or claret color of a kroyova. At 70 — 80% of patients bleeding stops spontaneously. A recurrence is observed at 22 — 38% of patients. The risk of the third bleeding after there was the second episode, reaches 50%.
The diagnosis demand coordinated actions of the gastroenterologist, radiologist and surgeon. After the direction of the patient diagnostic methods include an angiography and a kolonoskopiya in the intensive care care unit. The angiography and a kolonoskopiya can have not only diagnostic, but also therapeutic value as at patients with the proceeding bleeding during their carrying out an attempt to stop bleeding can be made.
The endoscopic stop of acute diverticular bleedings is carried out by local irrigation of the bleeding diverulikul by solution of Epinephrinum 1:1000, electrothermic coagulation and other ways. At inefficiency of these methods carry out segmented bowel resection. At most of patients diverticular bleeding stops independently. It is very important to exclude a tumor since neoplastic polyps and cancer can be the reason of the explicit or concealed hemorrhages from a rectum. Use of food fibers can prevent a diverticular disease. It is established that for prevention of a divertuculosis the diet has to contain not less than 32 g/day of food fibers.

Treatment of the Diverticulitis:

At an easy diverticulitis appoint inside an antibiotic of a wide range. At more serious disease of the patient it is necessary to hospitalize a surgical hospital. To it appoint the hunger and antibiotics inside operating on anaerobic and gram-negative microbes. Apply, in particular, amoxicillin, clindamycin and aminoglycosides (for example, gentamycin) or cephalosporins (for example, цефран, tseftatsidy, tsefotaksy, etc.), Biseptolum, metronidazole and квинолон. Improvement usually occurs within 2 — 3 days, in the next days the diet gradually extends. Treatment by antibiotics has to continue a current of 7 — 10 days. At the same time sick appoint intravenous therapy water and electrolytic solutions. In the absence of effect of conservative therapy surgical treatment is carried out. Surgical treatment can be recommended also at a recurrent diverticulitis and complications (fistulas, abscess). About 15 — 30% of patients with a diverticulitis are exposed to surgical treatment. The repeated attacks of an acute diverticulitis are observed, according to different authors, at 7 — 62% of patients. A recurrence of an acute diverticulitis answers worse therapy therefore after two attacks even of an easy diverticulitis the resection of an affected area of a gut is shown to the patient. Thanks to the surgical laparoscopic equipment operational treatment becomes more and more wide. However, the given Frizelle F.A. and соавт. (1997) at 10% of patients a diverticulitis recurrence after a surgical resection is possible.