By Dr. Michele D'Ambra SIUCP-ETS National Councilor
Introduction
By diverticulum we mean a structural alteration of the colon wall with the formation of sacs and/or pockets which are called diverticula.
Distribution in the population:
Prevalence 5% up to age 40; 40% at 60; 65% over 85
More common in males up to the sixth decade of life, then percentages comparable with the female population.
Statistical increase of 26% in recent years, especially in the younger age groups.
More frequent in the Western world due to type of diet and lifestyle.
The term diverticular disease includes several pathological entities ranging from asymptomatic diverticulosis (presence of diverticula only) to acute diverticulitis (inflammation or complications related to diverticula).
Symptoms
Approximately 20% of patients with diverticula develop clinical symptoms of varying intensity.
SUDD-Symptomatic Uncomplicated Diverticular Desease means the presence of abdominal pain and meteorism without other pathological conditions.
SCAD-Segmental Colitis Associated with Diverticulosis means a condition of segmental colitis associated with diverticulosis, a clinical picture usually found during endoscopic examination
Acute Diverticulitis means a clinical condition characterized by severe and prolonged abdominal pain, fever and alteration of inflammation indices (increase in white blood cells, CRP), up to conditions complicated by abscesses, perforations or peritonitis.
Diagnosis
Colonoscopy and Colon CT (Virtual Colonoscopy) are indicated by the evidence as the best methods to confirm or exclude the presence of diverticula.
Colonoscopy is the most reliable method in the management and diagnosis of diverticular disease, furthermore it can exclude the presence of inflammatory intestinal diseases or neoplasms.
The CT scan of the abdomen and pelvis with contrast medium is important as a complementary investigation in the diagnosis of diverticulosis but is fundamental in the diagnosis and staging of acute and complicated diverticulitis thanks also to the application of some radiological scores which help to classify the degree of severity among the most famous and used is the Hinchey classification.
How is diverticulosis treated?
Diverticulosis and asymptomatic diverticular disease are usually appropriately treated with a diet that includes an adequate intake of fiber and water, and sometimes with drugs that help control pain, colic spasm and changes in bowel movements. Among the most effective fibers is Methylcellulose, which vegetables, legumes and whole grains are rich in.
The use of antibiotics such as Rifaximin, probiotics and Mesalazine, although used in clinical practice, does not have strong scientific evidence on their usefulness in controlling symptoms or reducing the risk of complications.
Treatment of acute and complicated diverticulitis
Acute Diverticulitis or Complicated Diverticular Disease require more accurate management and clinical-diagnostic classification. Moderate cases can be controlled without hospitalization; this decision must be made by the treating doctor.
Hospitalization even in moderate cases may be recommended in elderly patients with numerous comorbidities or in patients with immunosuppression.
More serious cases require hospitalization, in the forms of acute, severe, complicated diverticulitis, in all European and American guidelines hospitalization, infusion support therapies, intravenous antibiotics are recommended.
Surgical treatment is reserved for patients with repeated attacks, severe or complicated cases and when there is a weak response or even no improvement after medical therapy.
The clinical pictures most frequently treated with surgery are perforation, abscesses, peritonitis, or pictures resulting from recurrent acute episodes such as strictures or chronic fistulas.
Among the most frequent emergency operations is the Hartmann operation, electively a sigmoidectomy or left hemicolectomy is performed (with or without AMI sparing) depending on the severity and extent of the pathology.
Minimally invasive laparoscopic surgery today plays a primary role in the surgical approach to diverticular disease, as it is always necessary in complicated cases to be able to count on a multidisciplinary approach. The involvement of an interventional radiologist or an urologist can be useful in reducing the invasiveness of the surgical intervention and reducing the need for ostomies.
A surgeon with Colo-Rectal experience can tackle the treatment of even complicated diverticular disease with effective strategies, a multidisciplinary approach and minimally invasive technique.