Diverticular Disease

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Diverticular Disease

 

Diverticular Disease

Diverticulosis is the formation of numerous tiny pockets, or diverticula, in the lining of the bowel. Diverticula, which can range from pea-size to much larger, are formed by increased pressure on weakened spots of the intestinal walls by gas, waste, or liquid. Diverticula can form while straining during a bowel movement, such as with constipation. They are most common in the lower portion of the large intestine (called the sigmoid colon).
 
Almost 50% of population presents colon diverticula. Most people will have no or few symptoms(diverticulosis). Sometimes they can refer symptoms like crampy pain and alternating diarrhea and constipation (diverticular disease) and a small percentage of patients will have complications like bleeding, inflammation, perforation.

 

Signs and symptoms

Because people with diverticulosis do not have any symptoms, it is usually found through tests (e.g. colonoscopy) ordered for an unrelated reason. Infection of a diverticulu determines a diverticulitis causing pain, fever and alternating diarrhea and costipation
 
In severe acute diverticulitis the inflammation of the colonic diverticulum may cause perforation or microperforation, determing a severe clinical feature of peritonitis and sepsis.
Diverticular disease can present with painless rectal bleeding as bright red blood per rectum. Diverticular bleeding is the most common cause of acute lower gastrointestinal bleeding, it is caused by erosions of small vessels of the mucosa.
Sometimes inflamed diverticula can cause narrowing of the bowel, leading to an obstruction
 

Diagnosis

In cases of asymptomatic diverticulosis, the diagnosis is usually made as an incidental finding on other investigations (e.g. colonoscopy).
Contrast CT is the investigation of choice in acute episodes of diverticulitis and where complications exist. This is an important tool to select the appropriate treatment and evaluate the severity of the disease ( Hinchey classification).
 

Management

Many people with diverticulosis have minimal to no symptoms, and do not require any specific treatment. A high-fiber diet and fiber supplements are advisable to prevent constipation.
Surgery for diverticulitis depends on its manifestation and complications. In non severe cases, antibiotherapy can be sufficient (if necessary combined with CT-guided drainage of abscesses). In severe cases, during emergency diverticulitis surgery, the perforated tract is removed and a colostomy or ileostomy is performed .
 
Complications, such as peritonitis, abscess, or fistula may require surgery, either immediately or on an elective basis. Whether the elective surgery should be performed is decided by external factors such as the stage of the disease, the age of the patient and his or her general medical condition, as well as the severity and frequency of attacks or if the symptoms persist after a first acute episode. In most cases, the decision to perform elective surgery is taken when the risks of the surgery are smaller than the ones resulting from complications of the condition. Elective surgery may be performed at least six weeks after recovery from acute diverticulitis.
 

Surgical approach

The procedure can be performed in open surgery or with a mini-invasive approach. Evidence shows that mini-invasive surgery is a safe as laparotomy in this type of surgery.
Laparoscopic approach allows to perform surgery using smaller incisions, determining a less post operative discomfort, a quicker recovery time, shorter hospital stay, earlier return to full activities, with a rapid return to their daily activities.