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A 10-Year Retrospective Study in 13680 Patients

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AbstractBackgroundMethodsResultsDiscussionData AvailabilityConflicts of InterestReferencesCopyrightRelated Articles

Introduction. Shared by certain epidemiological and etiological characteristics, diverticulosis and colorectal cancer (CRC) as well as colonic polyps has long been linked. This association was studied in several heterogeneous studies but has reported inconsistent results. Clarifying the association is clinically relevant for endoscopist awareness and potential modification of screening and surveillance intervals for diverticulosis patients. Methods. In this retrospective single-center study, patients diagnosed with diverticulosis on colonoscopy over a 10-year period were included. Each diverticulosis patient was matched with 1 control by age, gender, setting (inpatient/outpatient), and procedure’s indication. CRC and polyp detection rates were recorded and compared between the groups before and after adjustment for bowel preparation quality and exam completion. CRC location was recorded and compared between groups. Results. A cohort of 13680 patients (6840 patients with diverticulosis and 6840 matched controls) was included. Diverticulosis was located mainly to the sigmoid and left colon (94.4%). The CRC diagnosis rate was lower in the diverticulosis group (2% vs. 4.5%, , , and ). Moreover, location of CRC was unrelated to diverticulosis location, as more CRCs in the diverticulosis group were located proximal to the splenic flexure as compared to the control group (42.5% vs 29.5%, respectively; ). Diverticulosis, however, was associated with an increased polyp detection rate compared to controls (30.5% vs. 25.5%; , , and ). Conclusion. We demonstrated that diverticulosis was not associated with an increased risk for CRC. A possible increased polyp detection rate, however, warrants further evaluation in large prospective studies.

1. Background

Diverticulosis is considered as one of the most common and burdensome GI disorders [1, 2]. The underlying pathological mechanisms resulting in diverticular formation of a colonic wall is still largely unknown. Diverticula develop at well-defined points of weakness in the circular muscle of colon and are likely to be the result of complex interactions between environmental and heritable factors including diet, increased age, and decreased colonic motility, among others [3, 4]. Typically, diverticulosis is identified incidentally at colonoscopy or imaging studies performed for various indications, and the majority of patients with diverticulosis remain asymptomatic throughout their lifetime [5].

Several observations hold that certain epidemiological and etiological characteristics are shared between colonic diverticulosis and colorectal cancer, suggesting a possible association between these two conditions. The prevalence of these conditions is markedly on the rise in the last decades, and they both are detected frequently in aged people as well as western population and industrialized countries [6–8]. Western diet, namely, low dietary fiber and high total fat, has been largely regarded to play a major role in the pathogenesis and was epidemiologically associated with an increased risk of both conditions [9–13].

The abovementioned connection is of great clinical relevance, as several reports demonstrated that patients with diverticular disease have a higher risk of harboring colonic cancer [14–16]. Above and beyond, one meta-analysis demonstrated that diverticular disease was associated as well with increased detection of colorectal adenomas [17].

However, data are still controversial and inconclusive as other recent studies failed to confirm this association [18–20]. Moreover, the vast majority of the studies inspecting a possible link between both conditions were limited by small patient numbers and did not account for multiple confounders that are known to affect CRC and polyp detection such as patients’ demographics, procedure’s indication, setting, quality of bowel preparation, and exam completion.

Taken together, unraveling the dilemma and clarifying the association between both conditions appear to be clinically relevant, as modifying screening or surveillance intervals for CRC and polyp follow-up may be warranted accordingly in patients with diverticular disease.

The present study is aimed at comparing the CRC diagnosis rate and location as well as polyp detection rate between patients with diverticular disease and a matched group without diverticulosis with adjustment for abovementioned confounders.

2. Methods and Settings

We conducted a retrospective, large cohort study, which examined consecutive patients who underwent colonoscopies over a 10-year period within the gastroenterology department at the Hillel Yaffe Medical Center, a university-affiliated hospital in Israel. All patients’ data were collected from our department’s electronic record system. We searched endoscopy reports to identify all patients with a diagnosis of diverticulosis to create a study group. For a control group, each patient from the study group was matched with 1 control patient by age, gender, setting (inpatient/outpatient), and procedure’s indication. Patients were excluded if they were less than 18 years, had prior diagnosis of colon cancer, or if full data set is missing. Endoscopy findings including cancer diagnosis and location as well as polyp detection were recorded in both groups. Diverticulosis location was documented as well in the diverticulosis group. Whenever an endoscopic diagnosis of colorectal cancer was encountered, histology reports were reviewed to confirm diagnosis.

We compared the rate of CRC and polyp diagnosis between both groups and use multivariable analysis to adjust for adequacy of bowel preparation (adequate/inadequate) and depth of examination (cecal intubation confirmed or not), in order to identify independent association of diverticulosis with CRC and polyp detection. CRC location was documented according to endoscopy reports, and we compared its location between both groups. Diverticulosis and CRC location was classified as proximal (proximal to splenic flexure) or distal (splenic flexure or distal). The local institutional Helsinki ethics board approved the study and granted exemption from informed consent in this retrospective study as patients were receiving standard care without relation to the study.

3. Statistical Analysis

This statistical analysis is dealing with cohort of “big data” (40128 patients), of them 6840 patients with diverticulosis (study group). We used the Propensity Score Matching in R program version 3. 3 to divide the total cohort to 1 : 1 ratio (study and control group). Descriptive statistics in terms of mean, SD, and percentiles were preformed to the whole parameters in the study. Differences between the two groups (diverticulosis diagnosed vs. matched group) in the quantitative parameters were demonstrated by -test. For the categorical parameters, we used fisher exact tests. Multivariate logistic regression model was used to determine the effect of the independent parameters associated with CRC. SPSS version 25 was also used for statistical analysis. was considered as significant.

4. Results

We included a large cohort of 40128 patients who underwent colonoscopy at our hospital. We searched endoscopy reports and identified 6840 patients (17%) with diverticulosis diagnosed during the study period. A matched group of 6840 control patients (at 1 : 1 ratio) was included for final analysis. Baseline characteristics of both groups were similar and are provided in Table 1. The overall mean age was years (range: 18-101), with a slight male predominance (52. 1%). The vast majority of the procedures (78.4%) were performed in the outpatient setting. Procedures’ indications did not differ significantly between groups. The most common indications for colonoscopy were abdominal pain and diarrhea (21.1%), rectal bleeding (14.2%), and anemia (13.2%).

The CRC diagnosis rate was lower in the diverticulosis group (2% vs. 4.5%; ) while the polyp detection rate was surprisingly higher (30.5% vs. 25.5%; ) as compared to the matched group (Table 2). Cecal intubation rate (92.8% vs. 84.1%; ), adequate bowel preparation rate (90.7% vs. 84.1%; ), and terminal ileum intubation rate (2.2% vs. 1.6%; and ; ) were significantly higher in the diverticulosis group (Table 2). Multivariate analysis (Table 3) to account for these variables revealed similar trends as diverticulosis patients were associated with less CRC diagnosis (, , and ) but increased polyp detection rate (, , and ).

Diverticulosis and CRC locations are demonstrated in Table 4. Diverticulosis was located mainly to the distal colon (94. 4%). Location of CRC was unrelated to diverticulosis location, as more CRCs in the diverticulosis group were located proximally compared to the control group (42.5% vs. 29.5%, respectively; ).

5. Discussion

The current study was designed to clarify several aspects of diverticulosis and its possible association with CRC and polyp diagnosis. This association has long been studied in observational, cross-sectional, and case-control studies and has reported inconsistent results. Moreover, small patient numbers and heterogeneous study design contributed to conflicting conclusions. In the current study, we included a large cohort over a 10-year period and performed group matching followed with multivariate analysis in order to account for as many confounders as possible that may have influenced results of preceding studies.

We found that diverticulosis patients were not associated with an increased rate of CRC diagnosis compared to a matched group (2% vs. 4.5%; , , ). Our findings confirm the findings from other recent studies that diverticulosis is not associated with increased CRC diagnosis. A nationwide case-control study found that diverticular disease does not increase the risk of colon cancer in the long term, and a history of diverticular disease does not affect colon cancer mortality [18]. Our findings are also in concordance with a study by Meurs-Szojda et al. on more than 4200 colonoscopies which demonstrated a negative correlation between colon cancer and diverticulosis [21].

Moreover, we provided detailed location of diverticulosis and colon cancer in our cohort. Similar to different reports in western population [6, 7, 9], diverticulosis was located predominantly to the distal colon as more than 94% of diverticula were located to sigmoid and descending colon. In this regard, not only we demonstrated that CRC was located into sigmoid and descending colon in less than 35% but also we showed that more CRCs in the diverticulosis group were located proximally compared to the control group (Table 3) (42.5% vs. 29.5%, respectively; ). Consistent findings were reported by Cooper et al. who showed that diverticulosis associated interval cancers were somewhat more likely to be in the proximal colon and less likely to be in the distal colon [15]. Taken together, these findings reinforce the conclusion that CRC and diverticulosis are unrelated.

One worth mentioning finding in this study, however, is the increased polyp detection rate in diverticulosis patients (30.5% vs. 25.5%; 2, , ). This observation is supported by several other studies reporting that patients with diverticulosis have a higher risk of colorectal polyps as compared to those without [22, 23]. One meta-analysis found a significant 1.67-fold increased odds of developing adenomas in patients with diverticulosis [17]. Unfortunately, we were unable to determine the location and histologic type of these polyps in the current study. However, given the lower CRC diagnosis rate in the diverticulosis patients, this may point out that the majority of the detected polyps were of low dysplastic progression potentials (diminutive/hyperplastic polyps), thus explaining the low CRC diagnosis albeit the high PDR. Nevertheless, this observation needs further validation by a large prospective cohort study.

Furthermore, we demonstrated that diverticulosis has no significant effect on the outcome of colonoscopy. Linked with suboptimal bowel preparation, it is thought that diverticulosis may cause technical difficulty to perform a complete colonoscopy as a result of a spastic colon and luminal narrowing [24–26]. However, we demonstrated the contrary as quality indicators such as the cecal intubation rate (92.8% vs. 84.1%; and ; ) and the adequate bowel preparation rate (90.7% vs. 84.1%; and ; ) as well as the terminal ileum intubation rate (2.2% vs. 1.6%; and ; ) which were even better in diverticulosis patients compared to those without. Similar findings were reported by Gohil et al. who found that diverticulosis did not adversely affect the cecal intubation rate, withdrawal times, or sedation requirements [27].

One of the strengths of the current study includes the large number of participants involved as well as the inclusion of multiple factors such as procedures’ settings and indications reflecting real daily practice. Our study has limits inherent in its retrospective nature. Besides, other possible factors that may have affected endoscopy findings such as withdrawal time and variable endoscopist experience could not be obtained and were not included.

In conclusion, diverticulosis apparently is not linked with an increased risk of CRC but is possibly associated with an increased polyp detection rate. Prospective studies to clarify these findings are warranted.

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest

The authors certify that they have no affiliations with or involvement in any organization or entity with any financial or nonfinancial interest in the subject matter or materials discussed in this manuscript. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Copyright

Copyright © 2019 Fadi Abu Baker et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Diverticular disease (diverticulosis) of the colon

What is diverticular disease (diverticulosis) of the colon?

Diverticula (lat. diverticulum – literally “branch”, “road to the side”) are sac-like protrusions of all layers of the colon wall or only the mucous membrane and submucosal layer through a defect in the muscular layer.

Figure 1. Cross section of the colon. Diverticulum

Colon diverticulosis is a condition in which there is at least one diverticulum in the colon.

Figure 2. Diverticulosis of the left departments of the colon of

Diverticular disease – a disease characterized by clinical manifestations of the inflammatory process and its possible complications – abscesses, perforation of diverticulums, the formation of fistulas, peritonitis, as well as bleeding.

What is the anatomy of the large intestine?

To better understand the pathogenesis of diverticular disease, consider the anatomy of the colon. The large intestine is a hollow muscular organ – a “tube” located in the abdominal cavity in the shape of a “horseshoe”, and is the final section of the gastrointestinal tract, where the formation and evacuation of feces occurs. It consists of the following sections: appendix, cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum.

The wall of the large intestine consists of four layers: mucous, submucosal, muscular and serous.

Colon mucosa is its inner membrane facing the lumen. It is a thin layer of cells – a cylindrical epithelium. The mucous membrane lies on its own plate, consisting of loose fibrous connective tissue, in which the glands, blood and lymphatic vessels are located. In the deepest layer of the mucous membrane, on the border with the submucosa, there is a muscular plate of the mucous membrane. The epithelium of the mucous membrane performs an integumentary function, is a link between the wall of the large intestine and its lumen – it ensures the absorption of water, the synthesis of B and K vitamins by intestinal bacteria, the formation of fecal masses and their preparation for evacuation, releasing the required amount of mucus.

The submucosa is the layer of the colon wall following the muscularis mucosa. The submucosa contains blood vessels that feed the intestinal wall and nerve plexuses that coordinate its contractions. Due to the submucosa, the mucosa can shift in relation to the next layers of the colon wall and form folds.

Muscle fibers of the intestinal wall are arranged both circularly and longitudinally. This layer acts as a framework, and also ensures the promotion of fecal masses due to contractions.

Outside, the large intestine is covered with a thin “film” – a serous membrane.

For a better understanding of the mechanism of diverticulum formation, one should also pay attention to the peculiarities of the blood supply to the colon wall.

The colon is nourished from the system of superior and inferior mesenteric arteries, originating from the aorta, the main vessel of our body. Their branches form a single marginal vessel that accompanies the large intestine throughout its entire length. Feeding branches depart from the marginal vessel, passing through the muscle layer and branching in the submucosa. With an increase in pressure inside the intestine, sections of the muscular layer through which the feeding vessels pass can serve as a “gateway” for the formation of diverticula.

How does diverticular disease manifest itself?

Uncomplicated diverticulosis is usually asymptomatic – you may not even notice the disease. Diverticula may be an incidental finding during a routine examination. In this situation, no special treatment is required. Recommendations include regular medical supervision, a diet high in fiber and low in refined carbohydrates, and regular physical activity and weight control.

The difficulty of timely detection of diverticular disease lies in the absence of specific symptoms. The clinical picture is presented mainly by cramping pains mainly on the left lower abdomen, increased gas formation, unstable stools with a tendency to constipation or with alternating constipation and diarrhea. Such complaints are mainly associated with dysmotility of the colon.

When they see a doctor, such patients are usually diagnosed with irritable bowel syndrome or dolichosigma, the patient is reassured, an abdominal ultrasound is recommended, and after light therapy, they are sent “home”.

However, in the event of such complaints, a colonoscopy is mandatory! The above symptoms can be manifestations not only of diverticular disease, but also of many other diseases of the colon, the timely detection of which can significantly improve the results of treatment.

Figure 3. Colonoscopy. Orifices of diverticula are visible

The clinical picture of diverticulitis is significantly different. Severe abdominal pain, bloating, lack of stool, may be accompanied by fever, nausea, and vomiting. Such complaints require urgent hospitalization in the coloproctology department, where patients receive antibacterial, anti-inflammatory therapy, and if this treatment is not effective, surgical intervention may be necessary.

The main cause of inflammation of a diverticulum – diverticulitis – is the ingestion of dense fecal masses that are unable to come out. At this stage, inflammatory changes and the formation of an infiltrate (seal) of the surrounding tissues occur.

What causes diverticula?

Often at the doctor’s office, patients diagnosed with diverticular disease ask the question: “Why did this disease develop?” What are the causes of this disease? A large amount of information on the Internet does not always give a clear explanation. Let’s try to tell in more detail.

We believe that all the main causes of diverticular disease can be divided into two interrelated groups:

• Increased pressure in the intestinal lumen;
• Weakness of the intestinal wall.

Deficiency of vegetable fiber in the diet leads to a decrease in volume and an increase in the density of feces, which causes disturbances in the motor activity of the large intestine: even to a slight irritation, it reacts with chaotic contractions. Thus, short closed segments of the intestine with increased intraluminal pressure appear, which leads to bulging of the mucosa through the “weak” sections of the intestinal wall – the places where the blood vessels pass.

For a clear understanding of the formation of a diverticulum, we offer you an interesting comparison:

“The wall of the intestine is similar to the layered structure of a soccer ball – strong and hard skin on the outside, and a soft but elastic rubber chamber inside.

Now imagine that a hole, a hole, is formed in the outer hard shell of this ball. What will happen then? The high pressure inside the ball will push part of the soft and elastic inner rubber chamber outward: a pocket protruding outward is formed. This can be compared with a hernia on the abdomen – through a defect in the muscles, the contents “bulge out” outward.

Approximately the same thing happens with the large intestine in diverticulosis. If the pressure inside the intestinal lumen is large, and there are weak spots in the muscular layer, then the inner lining of the intestine tends outward through these holes, forming protrusions in the form of sacs. They are called diverticula.”

What tests should be performed if diverticular disease is suspected?

The first step in the diagnosis of diverticular disease without exacerbation is colonoscopy. With the help of a video camera inserted through the anus, more than a meter of the intestine is examined – the entire large intestine and the final section of the small intestine. Colonoscopy allows not only to see the presence of a diverticulum, but also to determine the size of its gate, the condition of the wall, and the exact localization. If other changes are found in the intestine, colonoscopy allows you to take a piece of tissue for examination – perform a biopsy with further histological examination in order to understand the microscopic structure of the changes. This study can be performed under light anesthesia, which allows you to completely save the patient from the discomfort associated with the procedure.

The “gold standard” for diagnosing diverticular disease is barium enema. This method allows you to determine the number of diverticula, their exact location, size and shape. The essence of the procedure is the introduction of a radiopaque preparation into the colon, after which a series of x-ray images are taken to assess the condition of the colon. In the presented photographs, the arrows indicate the orifices of the colonic diverticula. We marked with blue arrows multiple diverticula of the colon. This is what they look like on a CT scan.

Figure 4. Irrigoscopy. Diverticulosis of the colon

On x-ray images performed during irrigoscopy, multiple diverticula of the colon are clearly visible. They look like sacs filled with radiopaque.

Equally important methods are ultrasound diagnostics and computed tomography. Due to its minimally invasiveness, ease of implementation, ultrasound diagnostics is very relevant at the stage of the initial examination. It allows you to see the presence of diverticula, identify indirect signs of their inflammation, such as infiltration, abscess, or suggest a generalized form – peritonitis.

In order to clarify the data obtained during the ultrasound examination, in case of doubt and to clarify the diagnosis, a spiral computed tomography is performed. Virtual computed tomography allows you to recreate a three-dimensional image of the colon, including the affected areas. Using this technique, you can accurately determine the boundaries of the infiltrate or abscess, other organs involved in the inflammatory process.

Figure 5. Virtual colonoscopy. Orifice of diverticulum

How to treat diverticular disease, diverticulosis and diverticulitis?

Medical treatment

When treated promptly, diverticulitis responds very well to medical treatment. Inflammatory changes are completely cured with the help of antibacterial and anti-inflammatory therapy.

In case of complications of patients, the method of treatment should be selected the most minimally traumatic and minimally invasive. The infiltrate can be completely cured with medication. The abscess can be punctured under ultrasound or CT guidance.

Surgical treatment

In case of peritonitis and the need for surgery in the early stages of the disease, intervention can be performed laparoscopically – through small punctures. Unfortunately, the development of fecal peritonitis usually requires a laparotomy – a “large incision” for thorough washing and examination of the abdominal cavity.

Surgical treatment of diverticular disease without periods of exacerbation is especially important for active travelers, as well as patients living far from district centers. If an exacerbation of the disease occurs away from centers where you can get quality medical care, the consequences can be the most unpleasant. If there are three or more attacks of diverticulitis per year, the patient should contact the coloproctology department to determine the optimal treatment tactics outside the exacerbation period. If surgical treatment is necessary, the operation of choice in this case is the laparoscopic removal of the affected area of ​​the colon and the rectosigmoid junction as one of the causes of increased pressure in the intestinal lumen. Removal of the stoma (even temporarily) in this case is not required.

When is emergency surgery needed?

An urgent operation is necessary if purulent inflammation spreads to the peritoneum, i.e. peritonitis, which is a life-threatening complication.

Is the bowel always exposed to the anterior abdominal wall during an emergency operation?

This issue is decided individually for each patient. Of course, the formation of a stoma is not shown in 100% of cases.

Benefits of minimally invasive surgery for diverticulosis and diverticulitis

The main advantages of minimally invasive surgeries are a satisfactory cosmetic effect (there are no large scars on the anterior abdominal wall) and a faster patient recovery after surgery.

Will the intestine be exposed to the anterior abdominal wall (stoma formation) during a planned operation?

During planned surgical interventions for diverticulosis, the formation of an intestinal stoma is almost never required.

What happens after the operation?

You will be able to celebrate your recovery with your friends by strictly following your diet and doctor’s instructions.

Are there ways to prevent recurrence/recurrence of the disease?

First of all, avoid constipation and eating foods with small particles – nuts, seeds, fruits and vegetables with small stones.

How to choose a doctor and medical institution?

Choosing a clinic is a very important issue. Institutions with significant experience in the management of patients with diverticular disease should be selected. Our clinic employs specialists with extensive experience in performing minimally invasive operations.

Dear friends, if you or your loved ones have similar complaints or have already been diagnosed with diverticulosis, do not expect complications, you can always contact our clinic for advice, as well as modern treatment.

Intestinal diverticulosis – treatment of the sigmoid, colon and colon

Diverticular disease (diverticulosis) operating room. The reason for this situation is diverticular disease with a complicated course.

At present, it remains the subject of numerous discussions, seminars, conferences, due to the fact that the problem has not been finally resolved. Many problems can be avoided if a person understands what diverticular disease is, whether he belongs to the risk group for diverticulosis, how to prevent the development of the disease and its complications.

Epidemiology

Applicable to Russia and the former USSR, a rapid increase in the incidence of diverticular disease can be noted. In 1970, the incidence of the disease did not exceed 2-3 per 100,000 people. At 19In 1979 this number increased almost 6 times. According to the data published by the GNCC in 2002, the number of diverticulosis detected during X-ray examination was 14.2% of all coloproctological patients, and already in 2012 this figure doubled and amounted to 28.8%.

The growth of this disease is clearly seen along with the process of industrialization and urbanization due to changes in the way of life, lifestyle and nutrition of people. A decrease in the amount of dietary fiber consumed, a large amount of carbohydrate food with the use of red meat led to a significant jump in cases of diverticulosis.

In contrast, in developing agricultural countries, diverticular disease is characterized by isolated cases, which is determined by the nature of the diet, which includes a significant amount of plant foods. Aging society is another reason for the increase in the incidence of diverticular disease. It is noted that at the age of 40 years, the risk of developing diverticulosis varies within 5-10%. Whereas at the age of 60, the percentage of detected cases of the disease is already 30%, and by the age of 80 it exceeds 66%.

Thus, diverticular disease has been, is and remains a serious problem that poses challenges for physicians and patients. To understand the term diverticular disease, a brief description of the anatomy of the colon is necessary.

Anatomy of the colon

The colon consists of the following sections: cecum, ascending colon, transverse colon, descending colon, sigmoid colon. The cecum has the widest lumen, the sigmoid colon has the smallest. The junction of the sigmoid colon with the rectus is referred to as the rectosigmoid junction. It is important to note that this section of the intestine has the narrowest diameter.

The wall of the colon consists of three layers: serous, muscular and mucous. The function of the mucous membrane of the colon is the absorption of water, the formation of fecal masses, preparing them for evacuation by secreting a large amount of mucus and the synthesis of vitamins B and K. Under the epithelium of the colon mucosa there is a submucosa, represented by a loose fibrous connective tissue in which blood and lymphatic vessels and submucosal nerve plexus.

The muscular coat has a skeletal function and is responsible for the progressive movement of stool to the rectum. The muscular coat consists of a continuous inner circular layer, divided into three ribbons of the outer longitudinal layer.

The serous membrane consists of a connective tissue base covered with mesothelium, into which outgrowths of adipose tissue, the so-called fatty pendants, penetrate from the side of the muscular membrane

What is a diverticulum of the intestine intestinal wall. There are true diverticula, which have all the layers of the intestinal wall in the structure, and false – in which there is no muscle layer.

Diverticulum is divided into mouth, neck, body and bottom of the diverticulum. The blood supply of the diverticulum is carried out from the vessels of the submucosal layer, from which thin vascular branches depart, perforating the intestinal wall and heading to the bottom of the diverticulum.

When a diverticulum is formed in the projection of the fat suspension and the mesentery of the colon, it is covered on the outside with adipose tissue, when a diverticulum is formed in the free edge of the intestinal wall, it is covered on the outside only with a serous membrane.

• The number distinguishes between a single diverticulum and multiple diverticula of the colon.
• According to the localization of diverticula, right-sided, left-sided and total lesions of the colon are distinguished.
• Diverticulosis of right-sided localization, as a rule, has a congenital character with a predominance of true diverticula.
• With left-sided localization, diverticulosis in most cases is acquired and there is no muscle layer in the structure of diverticula.

Causes of diverticulosis

Causes of diverticular disease is still the subject of numerous discussions. There are several theories for the occurrence of diverticula. The most likely and most often discussed causes include: increased intraluminal pressure in the intestine, increasing weakness of the intestinal wall, impaired motility of the colon, and congenital predisposition.

Increased intraluminal pressure in the intestine:

Currently, the most recognized factor in the occurrence of diverticulosis is food. A decrease in the diet of plant fibers in the proper amount reduces the volume of feces, which in turn leads to a violation of their evacuation with an increase in intraluminal pressure in the intestine. The evidence is based on observations of vegetarians and residents of agrarian countries who consume a significant amount of fiber, in which the risk of diverticula is 42% lower than in a group of people who do not consume vegetable fibers in sufficient quantities.

Increasing weakness of the intestinal wall:

The fact of the appearance of diverticula in old age confirms the theory of weakness of the intestinal wall, which is a consequence of the aging process, when degenerative changes in muscle tissue and collagen fibers develop in the intestinal wall.

Impaired colonic motility:

Impaired intestinal motility leads to constipation and increased pressure in the intestinal lumen when stool evacuation is required. The loss of elasticity of the intestinal wall leads, when it is stretched, to micro-ruptures of the circular muscles, through which diverticula begin to form.

Vascular disorders in the intestinal wall:

It is impossible not to indicate the vascular component in the formation of the diverticulum. Violation of the blood supply leads to structural changes in the intestinal wall, while at the place where the vessel passes the muscle layer to the intestine, an expansion is formed, which over time transforms into the mouth of the diverticulum.

Congenital predisposition:

Various congenital systemic connective tissue diseases, collagenoses are a provoking factor in the development of diverticulum disease.

Diagnosis of diverticulosis

Irrigoscopy:

One of the most accessible diagnostic methods is irrigoscopy, which allows to reliably identify the location, size and number of diverticula. This method is not recommended for use in complicated cases due to the high risk of perforation of the inflamed diverticulum.

Colonoscopy:

A method to visualize diverticula and identify complications is colonoscopy. With this procedure, with sufficient reliability, it is possible to diagnose inflammatory changes in the region of the mouth of the diverticulum and detect bleeding from the diverticulum. ! This method cannot be recommended as a mandatory procedure if the patient has a clinical picture of an acute surgical disease of the abdominal organs.

Multislice computed tomography:

The safest method for diagnosing diverticular disease, both in the latent period and in diagnosing complications, is computed tomography, which allows not only to confirm the presence of diverticula in a patient, but also to determine the nature of complications. These include acute diverticulitis with perforation, abscess, peritonitis.

! despite the safety, this method is used to a limited extent due to the high cost of the study and inaccessibility, due to the lack of a MSCT machine in a number of hospitals.

Ultrasonography (ultrasound of the abdominal cavity):

An effective and affordable method for diagnosing complications of diverticular disease, reveals inflammatory changes in the colon wall, signs of abscess and peritonitis.

Laparoscopy:

Of the invasive methods for diagnosing complications of diverticular disease, laparoscopy should be noted, which can be considered not only as a diagnostic procedure, but also be of a therapeutic nature. With this method, it is possible to perform sanation measures for local peritonitis, drainage of the abdominal cavity.

Mechanism of development of diverticulum complications

Diverticular disease is a progressive disease. Diverticula do not undergo reverse development. The risk of developing diverticulitis with a 5-year existence of a diverticulum is approximately 10%. With a disease duration of more than 10 years, the risk increases to 25%.

Diverticulitis:

In diverticular disease, inflammatory changes develop in the wall of the diverticulum. The absence of a muscular layer leads to the fact that intestinal contents stagnate in them without the possibility of evacuation. This leads to the formation of fecalite (fecal stone) in the lumen of the diverticulum, followed by inflammation in the wall of the diverticulum.

Diverticulum perforation:

Inflammatory changes may be limited to the wall of the diverticulum with its edema and infiltration. With an aggressive microbial flora, inflammation takes on a malignant course and can lead to perforation of the diverticulum wall, which in turn can be delimited by the adjacent fatty tissue of the intestine or mesentery with the formation of an abscess. Violation of the integrity of the wall of the diverticulum can lead to serious complications in the form of peritonitis when the diverticulum is located on the free edge of the intestine.

Relapses of diverticulitis:

When acute inflammation is relieved, the diverticulum wall does not recover. The damaged mucosa is replaced by granulation tissue, which comes into close contact with the tissues surrounding the diverticulum, creating favorable conditions for a chronic inflammatory process and subsequent relapses of acute diverticulitis.

Bleeding from the diverticulum

Damage to the inflamed mucosa of the diverticulum by fecal matter when it exits the orifice or the development of a bedsore can lead to bleeding.

Fistula formation:

When inflammatory changes spread to nearby abdominal organs and / or the anterior abdominal wall, fistula formation is possible. Through such fistulas, intestinal contents can spread into the lumen of the bladder, the uterine cavity, and even to the anterior abdominal wall.

Classification and treatment of complicated diverticular disease

The Hinchey E.J. classification is widely used to characterize the complicated course of diverticular disease. proposed at 1978 year. ! Only a DOCTOR can establish the nature of the complication and prescribe the appropriate treatment. Do not self-medicate, this can lead to serious consequences!

Hinchey I.

Pericolic abscess or infiltrate: an acute condition caused by inflammation of the diverticulum with the possible formation of a limited abscess (abscess) in the mesentery of the colon or in its fatty suspension. The treatment of this complication is conservative, it consists in prescribing a strict diet and antibacterial drugs

Hinchey II.

Pelvic, intra-abdominal or retroperitoneal abscess. This condition is characterized by the formation of an abscess in a limited space in the abdominal cavity or in the retroperitoneal space outside the intestinal wall. Treatment consists of hospitalization in a surgical or coloproctological hospital, the appointment of bed rest, a strict diet, antibiotic therapy and detoxification treatment. If there is no effect, surgical treatment is indicated. As a rule, a sufficient volume of surgical intervention is the puncture of the abscess in order to evacuate it. However, in case of inefficiency, an emergency operation is indicated to remove the source of purulent infection. At this stage of the development of the disease, it is possible to perform a one-stage resection intervention with the restoration of intestinal continuity.

Hinchey III.

Generalized purulent peritonitis. A terrible complication that develops when an abscess breaks into the free abdominal cavity. Treatment is surgical only. With this complication, resection of the affected area of ​​the colon is performed with the formation of a stoma, sanitation and drainage of the abdominal cavity. Subsequently, a reconstructive intervention is performed aimed at restoring the natural passage through the intestines.

Hinchey IV.

Generalized fecal peritonitis. The most severe complication that develops in advanced cases, with late treatment of patients for medical care, in debilitated patients, people of senile age. The volume of the surgical operation is similar to the treatment for Hinchy III, however, the postoperative period requires long-term intensive care in the intensive care unit.

What to do if you have already undergone surgery for complicated diverticulosis with stoma removal

If you have already had emergency surgery and stoma removal, do not despair. Currently, methods for performing reconstructive interventions aimed at eliminating the stoma and restoring the natural passage through the intestine with good functional results have been developed and implemented. As a rule, these operations are recommended to be performed in specialized coloproctological hospitals.

Elective surgery for diverticulosis

Generally, surgery is not indicated after a single attack of diverticulitis, but may be recommended for people younger than 45 years of age. The decision to perform the operation is made individually. After successful conservative treatment of two or more episodes of diverticulitis, elective surgery is recommended.