Diverticulitis Flashcards
General findings (per la legge di La Place, la pressione transmurale al livello del sigma è maggiore, perchè il diametro è minore, e inoltre c'è una maggiore consistenza delle feci che contribuisce all'aumento pressorio)
Diet at risk: high-fat, low-fiber diet
Diverticular disease encompasses a set of colonic pathologies that result from abnormal outpouchings of the colonic mucosa (diverticula). It includes diverticulosis (noninflamed diverticula) and diverticulitis (inflamed diverticula). Colonic diverticula develop due to a combination of chronically elevated intraluminal pressures due to chronic constipation (e.g., due to low-fiber diets, lack of physical exercise) and age-related weakening of connective tissue👓 This causes the colonic mucosa to herniate through areas of weakness in the muscular layer. The sigmoid colon is most commonly involved. Incidence increases with age, and approx. 50% of individuals are affected by the 7th decade of life. Diverticulosis is typically asymptomatic but may manifest with lower gastrointestinal bleeding, altered bowel habits, and/or abdominal pain. Diverticulitis may remain localized (mild uncomplicated diverticulitis) or progress, resulting in complications such as abscess or perforation (complicated diverticulitis). Diverticulitis typically manifests with fever and left lower quadrant abdominal pain (as the sigmoid colon is most commonly involved). Colonoscopy is the diagnostic modality of choice for symptomatic diverticulosis but is contraindicated if acute diverticulitis is suspected. Abdominal CT scan with IV contrast is preferred in suspected acute diverticulitis. Uncomplicated diverticulitis usually responds to conservative management with bowel rest and analgesics; oral broad-spectrum antibiotics are reserved for patients at high risk of complications. In complicated diverticulitis, management consists of parenteral antibiotics, treatment of any complications, and, in some cases, emergency colonic resection. Once the acute phase has resolved, a colonoscopy is indicated to rule out malignancy. Elective colectomy is recommended for all patients with complicated diverticulitis that is managed conservatively. The procedure is not routinely indicated for uncomplicated diverticulitis.
Definition
NB La tendenza al sanguinamento, seppur asintomatico, è maggiore per i diverticoli rispetto alla diverticolite perchè la fase infiammatoria provoca uno stato fibrotico che riduce la facilità di sanguinamento.
Diverticula: blind pouches that protrude from the gastrointestinal wall and communicate with the lumen
-True diverticulum: a type of diverticulum that affects all layers of the intestinal wall.
Rare (except Meckel diverticulum )
Typically congenital
Most commonly occur in the cecum
Occur less commonly in the colon
-False diverticulum or pseudodiverticulum: type of diverticulum that involves only the mucosa and submucosa and does not contain muscular layer or adventitia🧨
Most common type of gastrointestinal diverticula
Typically acquired
Diverticulosis: the presence of multiple colonic diverticula without evidence of infection [1]
Diverticulitis: inflammation or infection of colonic diverticula
Etiology
Caused mainly by lifestyle and environmental factors
- Diet (low-fiber, rich in fat and red meat)
- Obesity
- Low physical activity
- Increasing age
- Smoking
Other causes: genetic factors
Connective tissue disorders (e.g., Marfan syndrome, Ehler-Danlos syndrome) [1][3]
Autosomal dominant polycystic kidney disease
Clinical finfings
Sia costipazione che diarrea! Nausea e vomito
✔Diverticulosis
- Usually asymptomatic
- May manifest with abdominal discomfort or pain, especially if associated with chronic constipation
✔Diverticulitis
-Low-grade fever💥
-Sigmoid colon most commonly affected → left lower quadrant pain !
-Possibly tender, palpable mass (pericolonic inflammation)
Change in bowel habits (constipation in ∼ 50% of cases and diarrhea in 25–35% of cases)
Nausea and vomiting (caused by bowel obstruction or ileus)
Acute abdomen: indicates possible perforation and peritonitis
↑ Urinary urgency and frequency (in ∼ 15% of cases)
Diverticolosi sintomatica
Colonoscopia!
✔Symptomatic diverticulosis
Colonoscopy: diagnostic modality of choice for suspected symptomatic diverticulosis
Indications
- Lower GI bleed
- Recurrent abdominal pain and/or diarrhea
- Concern for underlying malignancy
Findings: well-defined outpouching from the colonic wall
- Avoid if acute diverticulitis is suspected.
- Biopsy and histological analysis can be performed, if necessary
✔Abdominal ultrasound
Indications: may be performed as part of the workup for nonspecific LLQ pain
Diverticulitis
LLQ pain, fever, leukocytosis (presenti già dal grado 1 della classificazione CT scan)
Complicanze: ascesso peridiverticolare, perforazione, ostruzione
🧨Suspect acute diverticulitis in adult patients presenting with LLQ pain, fever, and leukocytosis. The diagnosis is confirmed with imaging, preferably with IV contrast-enhanced CT scan. Once the acute phase has resolved, a colonoscopy should be performed to rule out malignancy. Colonoscopy is contraindicated in the acute phase because of the risk of perforation.
Laboratory studies
Routine tests
1.CBC: leukocytosis, possible anemia
2.BMP: electrolyte abnormalities, ↑ BUN, ↑ creatinine
3.CRP: ↑ CRP
4.FOBT: positive in patients with diverticular bleeding
✔CT abdomen and pelvis with IV contrast
Indications
Preferred initial imaging modality for suspected diverticulitis
Staging the severity of diverticulitis:
-Colonic outpouching
-Signs of inflammation
-Bowel wall thickening > 3 mm
-Peridiverticular mesenteric fat stranding
-Complications may also be identified
1.Peridiverticular abscess: hypodense collections with peripheral contrast enhancement
2.Diverticular perforation: pneumoperitoneum
3.Intestinal obstruction: dilated intestinal loops with multiple air-fluid levels
✔Abdominal x-ray
Not useful in diagnosing uncomplicated diverticulitis
-Indications
1.Suspected perforation or bowel obstruction
2.May be performed as part of the routine workup for acute abdominal pain👓
Findings that may be seen in complicated diverticulitis include
-Bowel perforation: pneumoperitoneum
-Bowel obstruction: dilated bowel loops and multiple air-fluid levels
Recommended 6–8 weeks after the resolution of the acute episode to assess the extent of diverticulitis and rule out malignancy!💥
✔Uncomplicated diverticulitis: localized inflammation of a colonic diverticulum with no evidence of complications
✔Complicated diverticulitis: inflammation of a colonic diverticulum associated with complications such as perforation, abscess, fecal peritonitis, bowel obstruction, or fistula formation
The modified Hinchey classification is based on CT findings and is the most commonly used classification.
Treatment
1.Uncomplicated diverticulitis (cioè senza le complicanze di cui sopra)
Conservative management!
Consider broad-spectrum oral antibiotics (e.g., ciprofloxacin PLUS metronidazole) in select patient groups. (immunocompromessi, gravidanza)
2.Complicated diverticulitis
Inpatient management with broad-spectrum IV antibiotics is recommgended.
CT-guided percutaneous drainage for abscesses > 4 cm
Emergency colectomy in patients with generalized peritonitis
Grado 1: senza ascessi o ascesso pericolico minore di 5 cm. Il trattamento consiste nel limitare il transito intestinale (bowel rest), liquidi endovena e antibiotici ad ampio spettro (metridinazolo e ciprofloxacina)
Grado 2: ascesso pericolico maggiore di 5 cm. Terapia antibiotica IV e drenaggio dell’ascesso CT guidato.
Grado 3: peritonite diffusa, rottura ascesso, ascesso extrapelvico
Grado 4: peritonite diffusa fecaloide
Per i gradi 3 e 4, chirurgia d’urgenza. Colectomia mediante intervento di Hartmann, con stomia di protezione (colostomia). In casi selezionati con paziente stabile, laparoscopic or open colectomy and primary anastomosis with/without a temporary diverting stoma!
A seguito di remissione, dopo episodio acuto, procedere con colonoscopia per il controllo dell’estensione e per rule out malignancy. In generale, è indicata la chirurgia di resezione in elezione (Routinely recommended 6–8 weeks after resolution of complicated diverticulitis) nei soggetti con Hinchey II o chirurgia in elezione per i soggetti al secondo episodio Hinchey I. In questo caso è possibile eseguire una anastomosi primaria👓
Complicanze
- La diverticolosi è la causa più frequente di fistole coliche (seguita dal cancro del colon)
- la fistola più frequente è quella colon-vescicale (fecaluria, pneumaturia, IVU ricorrenti)
L’emorraggia dovuta a malattia diverticolare è la prima causa di emorragia digestiva bassa nei soggetti anziani. (5% dei pazienti con diverticolosi)
Gestione lower GI bleeding.
- Conservative managment: fluid resuscitation, trasfusioni e integrazione per deficit coagulativi (plasma fresco)
- Se fallisce il trattamento conservativo, COLONOSCOPIA diagnostico-terapeutica (colonoscopia in fase acuta perchè qui non c’è infiammazione in atto)
- Arteriografia con embolizzazione
- Surgery
Se si verificano più di due episodi di sanguinamento moderato-grave, si pone indicazione per resezione del sigma in elezione.
La vasopressina riduce la perfusione mesenterica, risultando ottimale per la fase di resuscitartion and preparation for elective surgery.
Prevention
- High-fiber diet
- Fluid hydration
- Weight reduction
- Vigorous physical activity
- Cessation of smoking
- Avoid nonaspirin NSAID use, if possible
SCENARIO Paziente di 75 anni si presenta in PS con addome estremamente dolente e dolorabile e segni di franco peritonismo. DOMANDA Quale delle seguenti non è una causa di ischemia intestinale?
Briglie aderenziali
Ernia strozzata
✔Diverticolo di Meckel
Volvolo
Intussuscezione
Il diverticolo di Meckel è un residuo del dotto onfalomesenterico a livello ileale. Tra quelle elencate non è una causa di ischemia intestinale.
