Take you to understand colonic diverticulitis from 5 aspects | Clinical Essentials

The introduction of colonic diverticulum refers to the sac-like pathological structure formed by the defect of the muscular layer of the intestinal wall of the colon, and the colonic mucosa protruding outward through here.

When symptoms of diverticulosis appear, it is called diverticulosis (DD), which usually includes symptomatic simple diverticulosis (SUDD) and diverticulitis.

DD and diverticulitis are the most common non-cancerous lesions of the colon.
In the past, they were thought to occur mostly in the elderly and were related to culture and eating habits.
However, diverticulitis is now increasingly seen in young patients (<50 years).

This article mainly reviews the epidemiology, risk factors, clinical manifestations, classification and staging and treatment methods of colonic diverticulitis.

The epidemiology and risk factors of colonic diverticulitis.
The occurrence of diverticulitis may be affected by physical/genetic and external environmental and nutritional factors.

Such as intestinal wall structure abnormalities, genetic defects, low-fiber diet, coexisting colonic allergic inflammation, habitual constipation, irritable bowel syndrome, chronic intestinal obstruction, and inflammatory bowel disease, etc.
The combined effect of factors such as changes in intestinal pressure changes.
Changes in wall structure and exercise capacity lead to DD and other complications.

Recent data indicate that patients with diverticulosis have a lower risk of developing diverticulitis than previously estimated.

In an 11-year follow-up study involving veterans with diverticulosis, the risk of diverticulitis was 1% as confirmed by computed tomography (CT) or surgery.

In a cohort of 2100 patients, the risk of diverticulitis during a median follow-up of 7 years was 4.
3%.

However, the overall incidence of diverticulitis is on the rise, and the prevalence rate is increasing in young patients.

Lifestyle factors may not be the only cause of diverticulosis, but once the diverticulum exists, lifestyle factors play a vital role in initiating the inflammatory cascade.

Clinical manifestations of colonic diverticulitis Diverticular disease usually does not cause any symptoms.

SUDD may have non-specific symptoms of pain and constipation.
Patients may exhibit high visceral sensitivity and normal bowel compliance.

The two most common complications of diverticulosis are bleeding (usually from non-inflammatory diverticula) and diverticulitis.

Diverticular bleeding may be sudden, from severe to massive bleeding in the lower gastrointestinal tract.

Clinically, acute diverticulitis usually manifests as increased abdominal pain, fever and increased inflammation indicators (leukocytes, C-reactive protein), with varying degrees of aggravation of symptoms.

A small number of patients with chronic diverticulitis show signs of diverticulosis-related segmental colitis (SCAD).

Classification and staging of colonic diverticulitis according to the different clinical symptoms, diverticulosis can be divided into 3 types: ①SUDD: mainly refers to the first attack without inflammation, such as abdominal discomfort or abdominal pain, bloating, diarrhea, constipation; ②recurring uncomplicated diverticulum Disease: once a year, no inflammation; ③complex diverticulosis: abdominal signs accompanied by inflammation, such as fever, diverticulitis.

The Hinchey staging system (1978) is used to determine the severity of acute diverticulitis based on clinical and surgical results.
The Hinchey staging system (2005) has been further modified to increase the subgroups of mild and complex acute diverticulitis and chronic complications (obstruction, Fistula) staging to determine the corresponding treatment standards (Table 1).

Table 1 Modified Hinchey staging system for acute diverticulitis.
Treatment of colonic diverticulitis.
Colonic diverticulosis is prone to recurrent attacks and has a high incidence of complications.
Surgery is the main treatment.

Patients with asymptomatic colonic diverticulosis generally do not need treatment.
For symptomatic colonic diverticulosis and its complications, medical treatment is the first priority.
Symptomatic treatments such as antibiotics, eating a high-fiber diet, and maintaining unobstructed stools can be used to relieve symptoms.
Prevent the development of complications.

Surgical treatment is required for colonic diverticulosis that has serious complications and is ineffective after conservative medical treatment.
If complications such as perforation, fistula formation, intestinal obstruction, and massive bleeding occur, emergency surgery is required. The clinical stage-based treatment methods for acute diverticulitis are as follows: ①Simple diverticulitis, most (>70%) of stage 0 and IA, the acute manifestations of diverticulitis are not complicated (stage 0 and IA), conservative treatment The success rate is high (>90%).

Whether it is for outpatients or inpatients, antibiotics are still the main method of initial non-surgical treatment.

The point is to set a time frame for the expected therapeutic effect.

For example, within 72 hours after starting appropriate treatment, the patient's symptoms and objective parameters [pain, fever, leukocytosis, systemic inflammatory response syndrome (SIRS), etc.
] must be improved or completely resolved/normalized without exception.

If this goal is not achieved, imaging examinations should be repeated to determine whether a drainable abscess has formed, or surgical intervention.

②Complex diverticulitis with abscess formation, stage IB and stage II treatment generally start with broad-spectrum antibiotics.

Small abscesses (<4 cm) may resolve with antibiotic treatment alone.

Larger abscesses, especially abscesses greater than 5 cm, require percutaneous drainage under imaging guidance.

The goal of treatment is similar to that of conservative treatment: within a prescribed time frame (for example, 72 hours), symptoms disappear, and objective clinical and inflammatory parameters return to normal.

Drug treatment including percutaneous abscess drainage during the initial hospitalization has a short-term failure rate of 12%-30%.
Surgical intervention should be carried out in time.

But even after clinical regression, the risk of disease recurrence is significantly higher.

③Complicated diverticulitis with free perforation and diffuse peritonitis, stage III (suppurative, non-suppurative) and stage IV (suppurative) perforating diverticulitis with peritonitis The best treatment method is still in terms of surgical indications and types of surgery It is constantly evolving.

Perhaps the most critical first step is to distinguish between patients with clinical evidence of diffuse peritonitis and a subgroup of patients whose imaging shows the presence of distant free gas but no clinical signs of sepsis or diffuse peritonitis.

The combination of clinical judgment and CT result analysis is essential for making reasonable decisions.

Conclusion As the population ages and diseases become more common among younger patient groups, the prevalence of diverticulitis is expected to increase substantially in the future.

CT is essential for the diagnosis of diverticulitis and the staging of the severity of DD.

The non-surgical treatment of diverticulitis is still mainly based on antibiotics, but mild patients can not be treated with antibiotics.

Supportive treatment may include probiotics or anti-inflammatory drugs, such as dietary changes.

Non-surgical treatment failure is usually defined as the patient’s symptoms and objective results (SIRS, leukocytosis) persisting or worsening 72 hours after the optimal treatment.

The failure of non-surgical treatment suggests that further intervention should be carried out, and the abscess should be drained by image-guided or surgical methods.

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