Introduction
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Colic diverticulum is a cystic pathological structure formed by the defect of the muscular layer of the colonic wall through which the colonic mucosa protrudes outward. When diverticulosis presents with symptoms, it is called diverticulosis (DD) and usually includes symptomatic simple diverticulosis (SUDD) and diverticulitis.
DD and diverticulitis, the most common noncancerous lesions of the colon, were thought to be more common in the elderly population and were associated with cultural and dietary habits. Related, but diverticulitis is increasingly seen in younger patients (<50 years). This article mainly reviews the content of colonic diverticulitisepidemiology, risk factors, clinical manifestations, classification and staging and treatment methods.
Epidemiology and risk factors for colonic diverticulitis
< span>The occurrence of diverticulum may be affected by both physical/genetic as well as external environmental and nutritional factors. Such as intestinal wall structural abnormalities, genetic defects, low-fiber diet, coexisting colon allergic inflammation, habitual constipation, irritable bowel syndrome, chronic intestinal obstruction and inflammatory bowel disease, etc. Changes in wall structure and motility can lead to DD and other complications.
Recent data suggest that patients with diverticulosis have a lower risk of developing diverticulitis than previously estimated. In an 11-year follow-up study of veterans with diverticulosis, the risk of developing diverticulitis confirmed by computed tomography (CT) or surgery was 1%. In a cohort of 2100 patients, the risk of developing diverticulitis during a median follow-up of 7 years was 4.3%.
However, the overall incidence of diverticulitis is on the rise, with an increasing prevalence observed in younger patients high. Lifestyle factors may not be the only cause of the development of diverticulosis, but once a diverticulum is present, lifestyle factors play a crucial role in initiating the inflammatory cascade.
Clinical manifestations of colonic diverticulitis
Diverticulosis Usually does not cause any symptoms. SUDD may present with nonspecific symptoms of pain and constipation, and patients may exhibit visceral hypersensitivity with normal bowel compliance.
The two true most common complications of diverticulosis are bleeding (usually from a non-inflammatory diverticulum) and diverticulitis. Diverticular bleeding may be sudden, ranging from severe to massive bleeding in the lower gastrointestinal tract. Clinically, acute diverticulitis usually manifests as aggravated abdominal pain, fever, and increased inflammatory markers (leukocytes, C-reactive protein), with varying degrees of aggravation of symptoms. A small subset of patients with chronic diverticulitis exhibited signs of diverticulosis-associated segmental colitis (SCAD).
Classification and staging of colonic diverticulitis
According to clinical Different symptoms, diverticulosis can be divided into three types: ①SUDD: mainly refers to the first attack without inflammatory manifestations, such as abdominal discomfort or abdominal pain, abdominal distension, diarrhea, constipation; ②Recurrent uncomplicated diverticulosis: once a year, no Inflammatory manifestations; ③ Complex diverticulosis: abdominal signs accompanied by inflammatory manifestations, such as fever and diverticulitis.
The Hinchey staging system (1978) was used to determine the severity of acute diverticulitis based on clinical and surgical findings, a further modified Hinchey staging system ( 2005) added subgroups of mild and complex acute diverticulitis and staging of chronic complications (obstruction, fistula) with the aim of determining the appropriate standard of care (Table 1).
Table 1 Modified Hinchey staging system for acute diverticulitis
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Treatment of colonic diverticulitis
Colic diverticulosis is prone to recurring attacks and has a high complication rate. Surgery is the main treatment method. Asymptomatic patients with colonic diverticulosis generally do not need treatment, but for symptomatic colonic diverticulosis and its complications, medical treatment should be the first priority. Prevent complications from developing. Surgical treatment is required for colonic diverticulosis with severe complications and ineffective conservative medical treatment. If complications such as perforation, fistula formation, intestinal obstruction, and massive bleeding occur, emergency surgery is required.
Clinical stage-based management of acute diverticulitis episodes is as follows:
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①Simple diverticulitis, stage 0 and stage IA
The vast majority (>70%) of diverticulitis present with uncomplicated acute presentations (stages 0 and IA), and conservative management has a high success rate (>90%). Antibiotics remain the primary method of initial nonsurgical treatment for both outpatient and inpatient settings. The point is to set a time frame for the expected therapeutic effect.
For example, within 72 hours of initiating appropriate therapy, the patient’s symptoms and objective parameters [pain, fever, leukocytosis, systemic inflammatory response syndrome] (SIRS) etc] must be improved or completely regressed/normalized without exception. If this goal is not achieved, imaging studies should be repeated to identify a drainable abscess, or surgical intervention should be performed.
②Complicated diverticulitis with abscess formation, stage IB and IStage I
Treatment generally begins with broad-spectrum antibiotics. Small abscesses (<4 cm) may resolve with antibiotics alone. Larger abscesses, especially >5 cm, require an attempt to place percutaneous drainage under image guidance. Treatment goals are similar to conservative treatment: symptom resolution and objective clinical and inflammatory parameters return to normal within a defined time frame (eg, 72 hours).
Drug therapy including percutaneous abscess drainage during initial hospitalization has a short-term failure rate of 12%-30%, and should be promptly perform surgical intervention. But even after clinical regression occurs, the risk of disease recurrence is significantly higher.
③Complicated diverticulitis with free perforation and diffuse peritonitis, stage III (purulent, non-purulent) and IV (purulent)
The optimal treatment of perforated diverticulitis with peritonitis remains in indication and type of surgery Growing. Perhaps the most critical first step is to differentiate between patients with clinical evidence of diffuse peritonitis and the subgroup of patients who have distant free gas on imaging but no clinical signs of sepsis or diffuse peritonitis. Combining clinical judgment and analysis of CT results is essential for making sound decisions.
Summary
With population aging and disease Having become more prevalent in younger patient populations, the prevalence of diverticulitis is expected to increase substantially in the future. CT is critical for the diagnosis of diverticulitis and staging of DD severity. Nonsurgical treatment of diverticulitis is still largely based on antibiotics, although mild cases may not be treated with antibiotics. Supportive care may include probiotics or anti-inflammatory drugs, such as dietary changes.
Non-operative treatment failure is usually defined as the persistence of symptoms and objective outcomes (SIRS, leukocytosis) 72 hours after optimal treatment or deteriorate. Failure of nonoperative treatment should prompt further intervention, including image-guided or surgical abscess drainage.
References:
p>[1] Suo Jian, Li Wei, Wang Daguang. Diagnosis and treatment strategies of colonic diverticulosis[J]. Chinese Journal of Practical Surgery, 2015, 35(05):562-563+566.< /p>
[2] International Consensus on Diverticulosis and Diverticular Disease. Statements from the 3rd International Symposium on Diverticular Disease[J]. J Gastrointestin Liver Dis. 2020 Jan 8;28 suppl.1:57-66 .
[3] Hanna MH, Kaiser AM. Update on the management of sigmoid diverticulitis[J]. World J Gastroenterol. 2021 Mar 7;27(9):760- 781.
[4] Ma Yong. Current status of diagnosis and treatment of colonic diverticulitis[J]. Capital Food and Medicine, 2015, 22(06):20-21.
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