Etiopathogenesis and medical history
The basis of the pathological process is the formation of diverticula. These are acquired protrusions of the intestinal wall that structurally resemble hernias. The mucosa and submucosa are pushed outward through anatomical defects in the muscular layer.
Such "weak spots" are not distributed randomly: they strictly correspond to the areas where branches of the mesenteric blood vessels pierce the intestinal wall. The medical history of patients with this pathology typically reveals a prolonged tendency toward constipation, which contributes to increased intraluminal pressure and the formation of protrusions.
Clinical presentation and complications
The uncomplicated form of the pathology is called diverticulosis. It is often completely asymptomatic and is discovered incidentally during radiological examinations performed for other reasons.
The main complication is diverticulitis — the onset of inflammation affecting the diverticulum itself, the surrounding tissues, and sometimes extending to the mucosa of the entire colon. Exacerbations can occur in two forms:
- Mild course: the patient experiences minor abdominal pain that can resolve spontaneously without specific treatment.
- Severe exacerbation: characterized by severe lower abdominal pain. The pain syndrome significantly intensifies during defecation and palpation. Signs of peritoneal irritation appear, along with a systemic inflammatory response (fever, leukocytosis in the blood test).
Severe pathomorphological consequences: The inflammatory process can lead to the formation of microabscesses around the affected area. Other dangerous complications include rectal bleeding (usually minor), the formation of large abscesses and fistulae. In the most severe and rare cases, perforation of the intestinal wall occurs, leading to diffuse peritonitis.
Instrumental diagnostic methods
Diagnostic workup is based on bowel visualization methods. The choice of a specific examination depends on the presence or absence of acute inflammation:
- Barium enema (X-ray examination). Considered the most valuable and informative method for uncomplicated diverticulosis. A classic three-stage technique or single-contrast imaging is used. Assessing the state of the colon after its complete evacuation is a mandatory element.
- Colonoscopy (endoscopic method). Allows the physician to visually assess the orifices of the diverticula (they can be single or multiple). A blood vessel can often be seen near the orifice. Pathological signs include increased tone and marked rigidity of the bowel wall, as well as spasm and difficult opening of adjacent physiological sphincters. If inflammation is present, the endoscopist may record pus discharging from the diverticular orifice.
- Computed tomography (CT). This is the method of choice in the acute stage of the disease (in diverticulitis). During an exacerbation, CT is preferred over a barium enema as it allows a detailed assessment of the state not only of the bowel wall itself, but also of the surrounding pericolic adipose tissue.
Treatment Management
The treatment approach directly depends on the phase of the pathological process (exacerbation or remission) and the presence of complications.
During an exacerbation: The patient is prescribed a sparing diet consisting of semi-liquid food. Medical support includes the use of laxatives and broad-spectrum antibacterial drugs (for example, tetracycline or ampicillin may be used).
During remission (outside of exacerbation): The main emphasis is on preventing constipation. A high-fiber diet is recommended. Mild laxatives are prescribed for regular stool regulation.
Symptomatic therapy: For severe pain syndrome associated with intestinal spasm, anticholinergic agents with atropine-like effects are used.
Briefly: answers to topical questions
Which classification is used to assess the severity of acute complicated diverticulitis?
The severity of acute complicated diverticulitis is assessed using the Hansen O. and Stock W. classification. Within this system, stage 2 corresponds to acute complicated diverticulitis and includes the following substages:
- Stage 2a — peridiverticulitis or phlegmonous diverticulitis;
- Stage 2b — diverticular abscess (contained diverticular perforation);
- Stage 2c — free perforation of a diverticulum into the abdominal cavity.
To assess the severity of perforated diverticulitis, the Hinchey classification is exclusively used, which divides the pathology into stages ranging from pericolic abscess to generalized fecal peritonitis.
What are the indications for surgical treatment of diverticular disease?
Indications for surgical treatment are divided into elective and emergency.
Emergency surgery is performed in cases of:
- diverticular disease complicated by peritonitis;
- failure of conservative and minimally invasive treatment of an abscess.
Absolute indications for elective surgical treatment include:
- inability to rule out a colonic tumor process;
- presence of a fistula.
Elective surgery is also indicated for signs of destruction of one of the diverticula and a high risk of recurrent life-threatening colonic bleeding. Relative indications are determined individually, taking into account the prognosis of the disease course and the severity of previous inflammatory complications.
Localization is easy to remember using the "weak vessel" rule: a hernia-like protrusion of the wall always seeks an exit where the muscular layer is already penetrated by branches of the mesenteric arteries.
Class and exam questions
What is the difference between diverticulosis and diverticulitis?
Diverticulosis is the presence of uncomplicated and often asymptomatic protrusions of the intestinal wall. Diverticulitis is the inflammation of these protrusions and the surrounding tissues, accompanied by pain and a systemic reaction.
Why is CT preferred over barium enema in acute exacerbations?
CT allows for the safe evaluation of not only the colon wall itself, but also the surrounding pericolic adipose tissue, detecting microabscesses and other complications, whereas forceful contrast administration during the acute stage can be hazardous.
What diet is indicated for patients with this pathology?
During an exacerbation, a sparing semi-liquid diet is necessary. During remission, conversely, a high-fiber diet is required to prevent constipation.
What else to study on this topic
- Pathophysiology of physiological sphincter spasm during inflammation
- Three-stage barium enema technique
- Mechanism of intestinal fistula and abscess formation
- Pharmacodynamics of atropine-like drugs in relieving intestinal spasms
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