Diverticulitis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Cafer Zorkun, M.D., Ph.D. [2] Ahmed Elsaiey, MBBCH [3]
Overview
Diverticulitis is a common digestive disease particularly found in the colon (the large intestine).[1] Diverticulitis develops from diverticulosis, which involves the formation of pouches (diverticula) on the outside of the colon. Diverticulitis results if one of these diverticula becomes inflamed or infected.[2] The colon can become infected with craters of food stuck inside, which causes abdominal pain.
Historical Perspective
Diverticulitis was first described by Dr. Lavater in the 1700s. Dr. Littre was the first one to describe the diverticular disease in the 1700s. Dr. Meckel gave a full description of the diverticulum in 1812.
Classification
Diverticulitis may be classified according to the German guidelines which were recently (2014) passed by the German Societies of Gastroenterology (DGVS) and of Visceral Surgery (DGAV). They unanimously agreed on another classification (Classification of Diverticular Disease (CDD)), which takes practical algorithms (symptomatic, asymptomatic, complicated, uncomplicated, acute, recurrent), ongoing surgical aspects (purulent vs. fecal peritonitis), and contemporary diagnostic standards in clinical practice into account. As a result, this classification comprises the entire spectrum of diverticular disease.
Pathophysiology
Diverticula is a protrusion of the intestinal layers consisting of mucosa and serosa. It occurs mainly on the left side more than the right side. Diverticulitis is the inflammation of this protrusion. The first step in the pathogenesis of diverticulitis is the increase of the intraluminal pressure, change of the intestinal motility and bacterial colonization. The inflammation is caused by histamine, tumor necrosis factor and metalloproteinases which were found in diverticulitis patient's tissue biopsies. Obstruction of the diverticula leads to bacteria colonization which leads to inflammation in the end.
Causes
Common causes of diverticulitis include diverticulosis, a low-fiber diet, constipation, abdominal distension, and Meckel's diverticulum.
Differentiating diverticulitis from Other Diseases
Diverticulitis must be differentiated from other diseases that cause lower abdominal pain and fever like appendicitis, inflammatory bowel disease, colon cancer, cystitis, and endometritis. Diverticulitis must be also differentiated from diseases causing peritonitis.
Epidemiology and Demographics
The prevalence of diverticulitis is 20,000 individuals at age 40 and 60,000 at age 60. The greater incidence is in patients between 18 to 44 years. Men and women are equally affected by diverticulitis at age 50-70 years and men are more affected at age more than 70 years. The prevalence has increased in the developed countries. In the United States, it has been around 312,000 cases admitted to the hospitals. In Japan, more cases of right side diverticulitis have been reported compared to the left side.
Risk Factors
The most potent risk factors for the disease recurrence include multiple diverticula, intraperitoneal abscess, family history of diverticulitis, and if a large portion of the colon involved in the disease.
Screening
There is insufficient evidence to recommend routine screening for diverticulitis.
Natural History, Complications, and Prognosis
Diverticulitis natural history is not well understood, but some studies showed a benign course if kept untreated. Diverticulitis can cause many complications that could be fatal in some cases. These complications include abscess, perforation, peritonitis and fistula formation. Prognosis of diverticulitis is excellent and conservative treatment is successful in 70 to 100 percent of patients.
Diagnosis
History and Symptoms
The most common symptoms of diverticulitis include left lower abdominal pain, fever, cramps, and constipation. A positive history of change of bowel habits is suggestive of diverticulitis. Less common symptoms include flatulence, nausea, and vomiting.
Physical Examination
Patients with diverticulitis usually appear toxic due to pain. Common physical examination findings include tachycardia, fever, abdominal tenderness,guarding and rebound tenderness, and a palpable mass can be felt. Diverticulitis diagnosis depends on taking a proper history and doing the physical examination. The known diagnostic criteria for diverticulitis includes abdominal tenderness especially in the left lower quadrant, leukocytosis and CT scan findings help in disease confirmation.
Laboratory Findings
Diverticulitis diagnosis starts by taking history precisely and perform the physical examination. Lab tests are important in excluding other causes of abdominal pain and any other gastrointestinal disease. These lab tests include CBC, CRP, urinalysis and liver tests. Imaging procedures are important measures in diagnosing diverticulitis including the CT scan and colonoscopy.[3][4]
CT scan
Abdominal CT scan is helpful in the diagnosis of diverticulitis. CT scan is not only important in the diagnosis of diverticulitis but also needed to exclude the possibility of cancer in these patients. It may also identify patients with complicated diverticulitis, such as those with an associated abscess. CT also allows for radiologically guided drainage of associated abscesses, possibly sparing a patient from immediate surgical intervention.
MRI
MRI is a good imaging modality that can be used in the diagnosis of diverticulitis since it has an advantage that there is no exposure to radiation and it rules out other abdominal causes of acute abdomen. However, it is not the best diagnostic procedure to diagnose diverticulitis and CT scan is preferred more. MRI shows specific findings of diverticulitis which include thickening of the colon wall, the presence of the diverticula, and exudates out of the colon. It may also show the presence of multiple abscesses.[5][6]
Ultrasound
Meckel's diverticula are usually seen as tubular incompressible blind ending hypoechoic structures with irregular margins. Occasionally it may also be seen as a cyst, raising a different differential diagnosis of intestinal duplication which, however, is said to have a regular margin.
X ray
On abdominal x ray, diverticulitis is characterized by multiple air and fluid levels if there is an intestinal perforation. The chest x-ray is important to be done in patients with diverticulitis to investigate for the pneumoperitoneum; which is a harbinger to a critical illness and will lead to change in the management plan in the case. X ray can be used in case the CT scan is not available and in uncomplicated cases.
Other imaging findings
There are no other specific imaging findings for diverticulitis. Other studies, such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.
Other diagnostic studies
There are no other specific diagnostic studies for diverticulitis. Other studies, such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.
Treatment
Medical Therapy
An initial episode of acute diverticulitis is usually treated with conservative medical management, including bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy which covers anaerobic bacteria and gram-negative rods. Patients who have recurring acute attacks or who develop diverticulitis-associated complications, such as peritonitis, abscess, or fistula, require surgery, either immediately or on an elective basis.
Surgery
Surgery is not the first-line treatment option for patients with diverticulitis. Emergency or urgent surgery is usually reserved for patients complicated withperitonitis, unresponsive to treatment, intestinal obstruction, and abscess formation. Elective surgery may be performed and it depends on many factors like the age of the patient, the severity score, and persistence of symptoms.
Prevention
Primary prevention of diverticulitis follows the prevention of constipation by using osmotic agents like lactulose, polyethylene glycol or magnesium salts. High fiber diet should be given till constipation improves. Using Laxatives and drinking plenty of fluids daily will be helpful.
References
- ↑ Diverticulosis and Diverticulitis. National Institute of Health - National Institute of Diabetes and Digestive and Kidney Diseases (2016). https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/diverticulosis-diverticulitis/Pages/overview.aspx Accessed on July 28, 2016
- ↑ Diverticulitis entry at Merriam Webster's Medical dictionary
- ↑ Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons (2006). "Practice parameters for sigmoid diverticulitis". Dis Colon Rectum. 49 (7): 939–44. doi:10.1007/s10350-006-0578-2. PMID 16741596.
- ↑ Käser SA, Fankhauser G, Glauser PM, Toia D, Maurer CA (2010). "Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis". World J Surg. 34 (11): 2717–22. doi:10.1007/s00268-010-0726-7. PMID 20645093.
- ↑ Stollman NH, Raskin JB (1999). "Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology". Am J Gastroenterol. 94 (11): 3110–21. doi:10.1111/j.1572-0241.1999.01501.x. PMID 10566700.
- ↑ McKee RF, Deignan RW, Krukowski ZH (1993). "Radiological investigation in acute diverticulitis". Br J Surg. 80 (5): 560–5. PMID 8518890.