الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 184 |  |  |
| | | from | 184 | | |
Abstract
Diverticular disease is an alteration of the colonic wall structure characterized by the presence of pockets called ‘diverticula’. These diverticula are characterized by herniation of the colonic mucosa and sub-mucosa through defects in the muscle layer at the weakest points in the colonic wall where blood vessels penetrate the wall of colon.
Diverticula occur commonly in the sigmoid and descending colon which is a common place for increased pressure. However it can occur at any site throughout the gastrointestinal tract.
By the age of 50 years old, approximately 50% of all people have diverticula, and nearly 70% of all people have diverticula by the age of 80 years old.
There is no sex predominance, with males and females being equally affected.
Most people with colonic diverticulosis remain asymptomatic, however about 20% of these patients will develop symptoms, which is called ‘diverticular disease’ (DD). 15 % of whom will ultimately develop complications. DD has a significant burden on westernized National Health Systems.
The underlying pathological mechanisms cause the formation of colonic diverticula, these are likely to be the result of complex interactions among diet, colonic microbiota, genetic factors, colonic motility, microscopic inflammation and structure changes. All these factors have to be considered as potential targets of treatment.
Major classification systems prompted the German Society for Gastroenterology and Digestive Diseases (DGVS) to propose a modified classification of diverticular disease, incorporating the best parts of other classification systems. Depicts the proposed classification, together with explanations of the different types of disease. The classification comprises various types of disease rather than stages because there is not necessarily a strong chronological order leading to chronic complications or diverticular bleeding.
Asymptomatic uncomplicated diverticulosis typically is diagnosed incidentally and does not require further work-up. Consensus guidelines recommend a high-fiber diet in these patients to prevent symptomatic diverticular disease.
Most people with colonic diverticulosis are unaware of this structural change. When symptoms do appear in a person over 40 years of age it is important to obtain medical advice and exclude more dangerous conditions such as cancer of the colon or rectum.
Classically, diverticulitis is characterized by acute, constant abdominal pain most often occurring in the left lower quadrant. The site of pain varies depending on the site of the involved diverticulum. Fever and leukocytosis generally are present. Other commonly associated symptoms include nausea, vomiting, and constipation or diarrhea. Some patients may complain of dysuria and frequency, reflecting what has been called “sympathetic cystitis” induced by bladder irritation from the adjacent inflamed colon.
Diverticular bleeding is the most common cause of lower gastrointestinal bleeding (LGIB). Diverticular bleeding is the source of 15 to 48 percent of lower gastrointestinal (GI) hemorrhage in adults, making it one of the most common causes of lower GI bleeding.
Abscesses occur when the pericolic tissues fail to control the spread of the inflammatory process. Abscess formation should be suspected when fever, leukocytosis, or both persist despite an adequate trial of appropriate antibiotics.
Free perforation into the peritoneum, causing frank peritonitis, can be life-threatening but is rare.
Colovesicular fistulas often present with pneumaturia and faecaluria. The passage of stool or flatus via the vagina is pathognomonic of a colovaginal fistula, which may also present with frequent vaginal infections or copious vaginal discharge.
Recurrent episodes of diverticulitis may cause progressive fibrosis and stricturing of the colonic wall, eventually leading to complete obstruction.
The choice of diagnostic procedure depends on the clinical presentation. Differential diagnosis in coexisting intestinal disease has to be considered. The first step in making the diagnosis is to establish patient history with respect to type, severity, and course of the symptoms. The second step may require barium enema, colonoscopy, laboratory tests, CT, sonography, or radiograph.
Patients who are asymptomatic, no treatment or follow-up needs to be offered, although there may be a prophylactic benefit of a high-fibre diet.
The nonoperative management of simple diverticulitis begins with appropriate antibiotics, bowel rest, and analgesia.
Hospitalisation, with intravenous antibiotic treatment, is usually recommended by current guidelines if the patient is unable to take oral therapy, is affected by severe comorbidity, if the patient fails to improve without patient therapy, or if patient is affected by complicated diverticulitis.
The indications for surgery are; purulent or faecal peritonitis, uncontrolled sepsis, fistula, obstruction and inability to exclude carcinoma.
There are two main types of surgery:
• Primary bowel resection. The surgeon removes diseased segments of your intestine and then reconnects the healthy segments (anastomosis). This allows you to have normal bowel movements. Depending on the amount of inflammation, you may have open surgery or a minimally invasive (laparoscopic) procedure.
• Bowel resection with colostomy. If you have so much inflammation that it’s not possible to rejoin your colon and rectum, the surgeon will perform a colostomy. An opening (stoma) in your abdominal wall is connected to the healthy part of your colon. Waste passes through the opening into a bag. Once the inflammation has eased, the colostomy may be reversed and the bowel reconnected.