Diverticular disease

General understanding

Diverticular disease (diverticulosis) of the  colon represents morpho-functional pathological process,  characteristic feature of which is the presence of saccular protrusions of the colon wall (Diverticula)

Diverticular disease - a disease characterized by clinical manifestations of varying degrees of severity due to the presence of a diverticulum or diverticulosis, including inflammation (diverticulitis) and its complications (peridiverticulitis, abscess, perforation, fistula, peritonitis)

Diverticulum - a protrusion of the colon wall. True diverticulum contain all layers of the colon wall. False diverticulum (pseudodiverticulum) represent the protrusion of mucous membrane through gaps in the muscular layer of the colon. Example of true diverticulum is the congenital diverticulum (Meckel's diverticulum), and the false diverticulum are the acquired diverticulum of the colon.

Diverticulosis - presence of multiple diverticulum without any clinical symptoms.

Diverticulitis - inflammation of diverticulum with development of clinical signs.

Meckel diverticulum – incomplete obliteration of the embryonic yolk duct or vitelline duck (congenital abnormality of the ileum). Meckel diverticulum lies at the antimesenteric border of the colon about 60-100 cm from the ileocecal angle. It is considered a true diverticulum because its wall comprises all the layers of the colon.
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• Epidemiology diverticular bowel disease
• Diverticular of the colon.
• Diverticular of the small intestine.

• Codes in ICD-10
• Diverticular disease of the bowel - K57.
• Diverticular disease of the small intestine with perforation and abscess - K57.0.
• Diverticular disease of small intestine without perforation and abscess - K57.1.
• Diverticular disease of the large intestine with perforation and abscess - K57.2.
• Diverticular disease of the colon without perforation and abscess - K57.3.
• Diverticular disease, and thin, and large intestine with perforation and abscess - K57.4.
• Diverticular disease, and thin, and large intestine without perforation or abscess - K57.5.
• Diverticular disease of intestine, part unspecified, with perforation and abscess - K57.8.
• Diverticular disease of intestine, part unspecified, without perforation and abscess - K57.9.
• Diverticular of Meckel - Q43.0.

• The aetiology of diverticular disease
• The pathogenesis of diverticular disease.  About 20% of the population suffer from diverticular diseases. The frequency of the disease increases with age, reaching 40-50% among patients aged 60-80 years. The diverticular disease is very rare aged up to 40 years.

Colon diverticulosis is more common in developed countries e.g. US and Europe and less common in the developing countries of Africa, South America, and Asia, this is because the inhabitants of the developing countries significantly eat high fibre diets. However, diverticular disease occurs at approximately the same rate in both men and women. About 10% of diverticular of the colon are congenital. The frequency of children born with Meckel's diverticulum in the population is 2-3%.  

Classification of diverticular bowel disease

Diverticular bowel disease distinguished by the localization:

The colon is the most frequent part of the GIT where this disease affects, this is explained by the anatomical and functional features of the colon i.e.  the colon is smaller in diameter with large number of haustri, denser texture content; sigmoid colon has a reservoir function, so it receives the pressure in the above.

The diverticular disease of the small intestine is less common. The most likely part of the small intestine to be affected is the distal part of the duodenum.  Approximately 70% of diverticular disease of the duodenum are located in the major duodenal papilla (usually 1-2 cm), and more often mimic the clinical symptoms (e.g., pancreatitis, cholangitis, jaundice, bleeding).

Aetiology and pathogenesis The causes of diverticular disease varied. The occurrence of disease is caused more by a combination of factors, not the action of a single factor.

Although the mechanism of diverticulum to this date is not clear, it is known that the disease occurs as a result of eating reduced dietary fibre, lack of physical exercise, obesity, constipation, segmental sphincterospasm, weakness of the colon wall and increasing the intraluminal pressure in the colon.

When food with insufficient dietary fibre passes through the colon, a large portion of its is absorbed and assimilated and only a small fraction of it remains in the colon which eventually becomes  stool or faeces. The peristaltic movements of food causes colon segmentation and intermittent functional obstacles in a number of colonic segments which leads to discoordination of the  activities of the longitudinal and circular muscle of the colon. As a result, the affected segment of the colon becomes less responding to the peristaltic stimuli. The mixing and propulsive function of affected colon segment also reduces, delaying the food contents to through the colon, thus increase the water and electrolytes absorption making the faeces to  become dry, consequently constipation develops, intraluminal pressure increase and the weak part of the colon wall protrudes. About up to 85% of diverticulum occurs sigmoid colon

Clinic and complications

• The clinical picture in diverticular disease of the colon

Approximately 2/3 of  colon diverticula do not present any clinical symptoms (asymptomatic diverticulosis) and most of the time they are accidentally diagnosed during endoscopic or radiographic studies. 

The main clinical manifestations of symptomatic diverticular disease of the colon:

• Recurrent pain in the left iliac region, disappearing after defecation and continued for several weeks, and sometimes months. Similar pain can sometimes be localized in mesogastrium in the right iliac region.
• Bloating and excessive gas in the colon (flatulence)
• Dyspepsia associated with concomitant hiatal hernia and gallstones (triad Saint-Diverticular disease, hiatal hernial, choledolithiasis).
• Rectal bleeding and the emergence of other colon symptoms (pain in the epigastric region, diarrhea, tenesmus) that cannot be associated only to diverticulosis without excluding other causes.
• Special forms of colonic diverticular diseaseThe special forms of diverticular disease of the colon according to the recommendations of the World Organization of Gastroenterology (2005):
• Diverticulosis the right (ascending) colon.Diverticular of the  right colon is very rare in Europeans but more common in Asians and is usually found in patients aged 25-50 years. This form of diverticular is more prone to bleeding. The diverticular of the cecum often leads to diverticulitis, which can cause differential diagnostic more difficulty.
• Diverticular disease of the colon in patients with reduced immunity. Diverticular disease of the colon in patients with reduced immunity (in patients with severe infectious diseases, diabetes, renal failure, cirrhosis of the liver, malignancies receiving chemotherapy drugs and immunosuppressive therapy, including corticosteroids) is characterized by less  severity of the clinical manifestations, and can cause complication  of the disease (especially perforations). Noted that corticosteroids and NSAIDs can cause acute diverticulitis. These drugs mask the usual symptoms of diverticulitis in the early stages, so a correct diagnosis is sometimes given very late , when already complication of the disease has occurred.
• Subacute diverticulitis.

          The term "sub-acute diverticulitis" can be severe and moderately severe when ongoing                         antibiotic therapy does not result in complete remedy of the clinical symptoms. In patients                  with chronic pain in the left iliac region develop temperatures up to subfebrile.

• "Smoldering" diverticulitis. Smoldering diverticulitis consists of abdominal pain and a change in bowel habit  without fever and leukocytosis, for 6-12 months marked pain in the left iliac region.
• Diverticulitis, recurrent diverticulitis after resection of the colon. Diverticulitis, recurrent after colon resection for diverticular disease occurs in 1-10% of patients undergoing this operation.Specialists involved in the problem of diverticular disease of the colon, insist on the need for the dynamic monitoring of all patients after the first episode of acute diverticulitis.An attempt was made to develop a prognostically significant criteria for the formation of groups of patients with high risk of recurrence of inflammation. It is established that the risk of recurrence of diverticulitis is higher if:

• The first episode of acute diverticulitis arose under the age of 60 years.
• There is intense pain in the left iliac region after the first episode of acute diverticulitis of the sigmoid colon.
• During the first examination of the patient inflammatory changes in the intestine are noted.
• Body temperature above 38,0 ° C.
• Detected at barium enema diverticula limited left divisions of the colon.
• Radiographic signs of a persistent increase in the tone of the left colon divisions that persist even in the face of drug hypotension.
• - showed signs previously transferred inflammatory process (fixing diverticula between themselves and the sigmoid colon into the surrounding tissue in conjunction with the deformation of the circuit).

• Complications of diverticular disease of the colon
• Diverticulitis. risk factors for diverticulitis are the presence of a history of diverticulitis, and the presence of multiple diverticula of the colon. Diverticulitis is observed in approximately 25% of patients with diverticulosis. The main features of diverticulitis include:
• Acute onset - pain and muscle tension of the anterior abdominal wall in the left lower quadrant.
• With the progression of the disease - fever, chills.
• Anorexia, nausea, vomiting.
• Diarrhea or constipation.
• Painful inactive dense infiltrate in the abdominal cavity (spreading of the inflammatory process with diverticulum of the surrounding tissue).
• the involvement of the bladder - dysuria.

• Perforation.
• When diverticulum perforation into the abdominal cavity develops clinical peritonitis, infiltrates or abscesses, edema of the neck of a diverticulum, occlusion.
• Bleeding. Bleeding is associated with ulceration of the neck or wall of the diverticular vessel Bleeding from the diverticulum may occur in patients with essential hypertension, atherosclerosis, heart diseases, blood diseases and long-term use of corticosteroids. The volume of blood loss is different: blood can be lost in the stool (sometimes occult blood), massive bleeding, accompanied by  collapse and sometimes leading to death.

• Ileus.  The cause of intestinal obstruction can be inflammatory infiltrate, adhesions, invagination of the portion of the bowel in the diverticulum or smooth muscle spasm. Ileus with diverticulosis often has the character of all manifestations of obstructive inherent in this form.

• Internal or, more rarely, the external intestinal fistulas.
• Men often develop sigmovesical fistulas in women - sigmovaginal.
• When forming internal fistulas may form a complex system sinus passages opening on the skin of the anterior abdominal wall.
• In the formation of the enteric-vesical fistula - pneumaturia, fecaluria.
• Malabsorption. Diverticula of the small intestine can lead to the development of malabsorption syndrome due to excessive growth of bacterial flora.

• The clinical picture in diverticular disease of the small intestine

Diverticula of the small intestine often asymptomatic. Only occasionally they lead to stasis of enteric content, bacterial overgrowth and malabsorption. Perforation, inflammation and bleeding occur much less frequently than with diverticulosis of the colon.

The most common diverticula of the duodenum. Clinical signs of diverticular disease of the duodenum arise only when complications of the disease.

• Diverticula upper horizontal card manifested clinical symptoms of peptic ulcer disease, which is associated with a hit in a diverticulum acid content and appearance there of erosion and ulcers.
• Descending colon diverticulum card in the event of the inflammatory process may lead to large compression duodenal papilla (papilla of Vater), followed by development cholangitis, pancreatitis, obstructive jaundice.
• Possible and direct transition of inflammation in the pancreas to the development of chronic pancreatitis.
• Diverticula of the lower horizontal department in the development of diverticulitis can cause compression of the duodenum and cause its obstruction.

• Meckel's diverticulum and its complications

In 95% of cases the disease is asymptomatic. The clinical picture of Meckel diverticulum occurs primarily when there are complications, which include:

• Peptic ulceration of the ileum. In children, there is peptic ulceration of the surrounding mucosa of the ileum, which is often the cause of massive gastrointestinal bleeding.

• Acute diverticulitis. Clinical manifestations of acute diverticulitis is so similar to the symptoms of acute appendicitis, the differential diagnosis before surgery is practically impossible. If during the operation found intact appendix, it is necessary to revision the ileum about over 100 cm from the ileocecal angle.

• ileus. It occurs due to intussusception, volvulus of the small intestine around diverticulum, caused by chronic diverticulitis adhesions.

• Perforating diverticula. Usually occurs as a result of its inflammation and ulceration, at least - as a result of bedsores fecal stone or foreign body.

• Malignancy ectopic gastric mucosa with the development of cancer.
• The simultaneous combination of several complications.

Diagnostics

Diverticular disease can cause regular pain in the left or, at least, the right iliac region, which decreased after the act of defecation.

In most cases, intestinal diverticular disease is not manifested by the presence of any symptoms and accidentally detect by X-ray or endoscopic examination of the bowel.

• diagnostics purpose
• Localization and prevalence of lesions.
• Identifying complications.

• methods of diagnosis Diagnosis diverticular disease involves analysis of clinical manifestations of the disease, medical history, physical examination of patient data.
• anamnesis. When collecting history pay attention to the age of the patient, race,  the European (often the left side of the colon is affected) or Asian (predominantly affects the right departments) origin. It is necessary to ask the patient about the presence of complaints characteristic of diverticular disease or its complications, limitation of their emergence and development dynamics.

• Laboratory Diagnostic Methods
• General blood analysis. When diverticulosis number of leukocytes in peripheral blood usually remains within normal limits. When diverticulitis often arise leukocyte shift to the left, increasing ESR . The appearance of bleeding causes iron deficiency anemia.
• General urine analysis. The urine can be detected leukocytes, erythrocytes, components of intestinal contents. In the formation of the enteric-vesical fistula detected in urine bacteria, specific to the intestines.

• General analysis of feces (coprogram). These coprological studies confirming the presence of inflammation: polymorphonuclear leukocytes, mucus admixture to a large number of macrophages, desquamated epithelium.
• Imaging diagnostic methods and tools.  Panoramic radiography of abdominal organs. Plain radiography is performed to exclude diverticulum perforation, which is manifested accumulation of free gas in the abdominal cavity. Radiography is performed in the horizontal and vertical positions.

Ergography.

Radiographic manifestations of diverticulosis are characterized not only by the presence of multiple diverticula, but the asymmetry haustrum, as well as changes in compliance intestine that is revealed on closer the study. In the case of uncomplicated diverticulosis X-ray diagnosis of diverticular sacs is not difficult.

Diverticula identified as a rounded protrusion or finger-shaped isthmus connected with the lumen of the colon.

When diverticulitis barium permanently retained in the lumen of the diverticulum, and notes its deformation unevenness circuit isthmus stenosis, muscular spasm resistant hypersegmentation with the corresponding region of the colon and luminal narrowing.

Latency contrasting masses in diverticula from 2 up to 10-15 days or more - distinctive sign diverticulitis.

Barium slurry can pass through the perforated diverticulum in the abscess cavity (fistula), and abscesses may cause deformation of the outer lumen of the intestine.

             

Ergography. Multiple diverticula of the colon and the sigmoid colon.

Ergography. Perienteric abscesses (indicated by arrows) with diverticular disease of the colon.

Ergography. Determined contrast output into the abdominal cavity (sign perforation) in the right portion of the transverse colon.

• Endoscopic examination.

If endoscopy is not difficult to inspect the affected segment. Mouth diverticula can be detected by endoscopy if they are disclosed. In diverticulum zone determined rigidity and increased tone of the intestinal wall. When diverticula close to the physiological sphincter last spasmatic disclosed only with difficulty. Hypertonus of the colon often leads to closing of the mouths of the diverticula, making them difficult to diagnose during a colonoscopy.

Diverticula are arranged linearly. When endoscopy can skip diverticula, if the line of their location drops out of sight (blind spots). Furthermore, the mouth of diverticula often covered with intestinal contents or are closed due to spastic kolodiskinezii. Consequently, the role of endoscopy in the diagnosis of diverticular disease is limited.

Colonoscopy is contraindicated in the presence of pronounced inflammation.

Colonoscopy, nevertheless, provides a valuable technique for detecting such accompanying lesions as polyps and cancer, which may be unrecognized at barium enema. Biopsy diverticulum is contraindicated, as it can cause bowel perforation.

Colonoscopy allows you to identify the source of intestinal bleeding.

Endoscopic picture of acute diverticulitis represented hyperemia and edema of the mucosa in the diverticulum may be found in the gut pus. The study should be conducted carefully, a minimum air insufflation avoid damage diverticular wall.

Diverticulosis of the sigmoid colon.

• CT scan.

CT is used in the acute stage of the disease for the assessment of the intestinal wall and perienteric tissues.

In the diagnosis of diverticulitis is especially effective contrast-enhanced computed tomography. Diagnostic criteria for diverticulitis:

• Local thickening of the colon wall (5 mm).
• Perienteric inflammation of adipose tissue.
• Perienteric presence of an abscess.
• US.

Ultrasound examination at a sufficient qualification allows the researcher to establish for diverticulitis:

• Thickening of the bowel wall.
• Perienteric inflammation of adipose tissue.
• Intramural and extraintestinal infiltrative education.
• Intramural fistulas.
• Cystoscopy and tsistografiya.

Studies have shown for the diagnosis of vesico-intestinal fistula.

Scheme of cystoscopy.

• Intravenous urography.

It allows you to set the possible involvement in the inflammatory process of the ureters.

• Angiography.

The diagnostic method used for bleeding of the diverticulum. Possible to carry out therapeutic measures by embolization of the bleeding vessel.

Angiography. Determined extravagates (a sign of bleeding) in the descending colon.

• Fistulography.

This diagnostic method is used in the development of intestinal fistulas to establish their connection with the gut.

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• Plan (tactics) diagnostics
• Diagnosis should begin with a survey radiography of the abdomen in order to avoid perforation of the diverticulum. The method of choice for uncomplicated diverticular disease of the colon is a barium enema.
• Endoscopy reveals the presence of multiple diverticula, gastrointestinal bleeding, and may also be useful for the detection of related lesions as polyps and cancer, which may remain undetected when barium enema.
• Colonoscopy is contraindicated in patients with severe inflammation.
• In the diagnosis of diverticulitis is especially effective contrast-enhanced computed tomography.

• differential diagnosis

When the complicated forms of diverticular disease of the colon differential diagnosis is difficult. Clinical manifestations colon diverticulosis and its complications can not serve as a basis for establishing an accurate diagnosis of the disease. Diagnosis and differential diagnosis of colonic diverticulitis is based on the analysis of the clinical manifestations of the disease and the results of the mandatory x-ray and endoscopic examination of the colon.

Elderly patients should be an exception ischemic colitis, colon cancer, intestinal obstruction, penetrating ulcers of the stomach or duodenum, nephrolithiasis / urosepsis, acute cholecystitis.

In patients young and middle-aged exclude acute salpingitis (in women), acute appendicitis, urosepsis, inflammatory bowel disease (Crohn's disease), penetrating ulcer of the stomach or duodenum, angiodysplasia (with bleeding).

In the presence of fistulae (kolovezikalnyh, kolovaginalnyh) should be deleted Crohn's disease, previous radiotherapy pelvic preceding gynecological surgery, pelvic abscesses.

In identifying the strictures of the colon especially differential diagnosis with malignant tumors. Unlike strictures that developed due to diverticulitis:

• The presence of diverticula in the colon.
• Strictures diverticulitis at longer (3-6 cm in length) are more smooth contours (in cancer stricture sharp edges on both sides, the length up to 3 cm in Crohn's disease stricture length - 10.6 cm; stricture in splenic flexure most often caused by ischemic colitis).

Treatment

• General principles of treatment of intestinal diverticular disease
• When diverticulosis with clinical manifestations, but without toxicity, in the absence of symptoms of irritation of the peritoneum and leukocytosis may outpatient treatment under medical supervision.
• When diverticulosis with a complicated passage shown in a specialized hospital treatment compartment (Colorectal).
• Treatment diverticular disease may involve the use of both conservative and surgical treatments.

• treatment goals
• Prevention of disease progression and development of complications.
• Normalization of bowel function and relief of exacerbations.
• Treatment of complications when they occur.

• Methods of treatment of diverticular disease of the intestine
• dietary management

All patients with diverticulosis should eat diet with  high content of fiber. Wheat bran significantly reduce intraluminal pressure and accelerate the speed of intestinal content migration. All patients with diverticulosis need to avoid foods that cause flatulence (beans, grapes, lentils, onions) and constipation (blueberries, rice), and  eliminate seeds, fruits with more rough grains and excessive fiber (persimmon, pineapple, turnip, radish, radish).

• medication
• When diverticulosis.
• When pain syndrome is used spasmolytics ( papaverine ( Papaverine hydrochloride 2% solution ) 2.1 ml n / a or / m,bencyclane ( Halidorum ) 0.05 g / m or drotaverine ( Nospanum ) 2% p -p 2-4 ml / m) at a pain syndrome.
• To enhance the motility of the stomach and intestines - pyridostigmine ( Kalimin ) 0.06 g 3.1 p / day orally or 5.2 mg of p / c or i / m or
• metoclopramide ( Reglan ) 10 mg 3 / day orally (prior to eating) or / m.
• In identifying dysbacteriosis to restore the normal intestinal microflora - Bifidumbacterin or Bifikol .
• At constant constipation - vaseline or olive oil inside or microclyster.
• When mild diverticulitis.

When mild diverticulitis (moderate pain, well localized in the left iliac region, low-grade fever and slight leukocytosis, no symptoms of intoxication and vomiting) treatment comprises administering to the inside for 10-14 days:

• metronidazole ( Trichopolum , Flagyl ) 500 mg of 2p / day + trimethoprim / sulfamethoxazole ( co-trimoxazole ) (Biseptolum , Bactrim ) to 960 mg / day - 3 days, followed by 480mg / day - 9-11 days or
• metronidazole ( Trichopolum , Flagyl ) 500 mg of 2p / day + ciprofloxacin ( Tsiprobay , Ciprolet ) 500 mg of 2 r / d.
• When srednetyazholoy form diverticulitis.

When srednetyazholoy form diverticulitis (localized pain in the lower left quadrant, febrile fever, leukocytosis with "left" shift palpation pain, intoxication symptoms, nausea, vomiting) treatment comprises parenteral administration of one of the below mentioned antibacterial agents with a broad spectrum of action to permit activity process:

• meropenem ( Meronem ) 500 mg / every 8 hours or
• Ciprofloxacin ( Tsiprolet , TSifran ) 400mg / in 3 r / d or
• cefotaxime ( claforan , Céfotaxime ) 2 g every 12 h or
• Clindamycin 600 mg / every 8 h + metronidazole ( Clione , Metrogyl ) 500 mg / drip every 8 hours or
• amoxicillin ( Amoksiklav ) 50 mg / kg of body weight per day / m every 6 hours + metronidazole ( Clione , Metrogil ) 500 mg / drip every 8 hours.
• By inhibiting the activity of the process continues to the patient symptomatic therapy. The criteria for an end of intensive treatment is a clinical-laboratory remission with normalization of the blood picture.

• Surgery

Indications for surgery:

• Emergency indications for surgical treatment! Complications of diverticulosis, posing an immediate threat to the life of the patient (diverticulum perforation into the abdominal cavity with the development of diffuse peritonitis, intestinal obstruction, massive bleeding).
• The presence of a fistula.
• Education chronic infiltrates simulating a tumor.
• Frequent exacerbations of chronic diverticulosis.
• Currently, surgery is increasingly used and uncomplicated, but symptomatic diverticulosis, not amenable to complex conservative treatment.

Selection operation method in each case depends on the following factors:

• The nature and prevalence of complications of the process.
• Inflammatory tissue changes diverticulum, colonic wall and surrounding tissues.
• Availability of perifocal inflammation or peritonitis.
• It is also important co-morbidities often seen in the elderly.

Surgical treatment for different types of diverticular disease

• Surgical treatment of diverticulitis.

It is preferable to perform a resection of the colon in a planned manner with simultaneous anastomosis. The operation was performed in about 6-12 weeks after the relief of acute attacks of diverticulitis.

• Surgical treatment in the presence of fistulae.

Fistulas of the colon in patients with diverticular disease are subject to surgical treatment, as the majority of patients self-healing does not occur, and chronic inflammation in the surrounding tissues leads to the development of chronic intoxication. In forming the enteric fistulas cystic there is a threat of an ascending urinary tract infection.

Surgical interventions in patients with complex fistulas (having multiple sinus tracts, including blindly ending) in the presence of cavities parafistulyarnyh advantageously carried out in several stages, thus reducing the mortality rate and reduce the recurrence rate of fistula.

• Surgical treatment of intestinal bleeding.

If breakthrough bleeding should be performed hemicolectomy, mostly left-handed.

The issue of primary anastomosis should be dealt with individually, based on the overall condition of the patient, severity of anemia and quality of preoperative preparation of the colon.

• Surgical treatment of bowel perforation.

The choice of surgery for bowel perforation with acute diverticulitis should be strictly individual:

• Sigmoid colon resection with primary anastomosis - the most effective method of treatment in the event of local demarcated abscesses. Delimited the presence of an abscess is not considered a contraindication for primary anastomosis if the bowel areas involved in anastomosis, are not involved in the inflammatory process and there is no immunodeficiency.
• Resection of the sigmoid colon with primary anastomosis and proximal colostomy deducing the discharge portion of the anastomosis (e.g., transverzostoma).
• Resection involved in the pathological process segment sigmoid colostomy with breeding end and suturing the distal colon segment (Hartmann type of operation). Following subsiding inflammation (usually 2.5-3 months) operate reconstructive surgery, restoring the anatomical continuity of the colon.
• Overlay unloading double-barreled transversectomy and drainage of the abscess cavity (always with a "spur" and the intersection of both ends of the intestine).
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• Clinical management of diverticular disease of the intestine
• Clinical management of diverticular disease of the colon.
• In asymptomatic bowel diverticulosis as discovered by chance in a special treatment need arises. Recommend rich plant fiber diet to prevent further progression of the disease and prevent possible complications.
• When diverticulosis with severe clinical manifestations of a complex of therapeutic measures: laxative diet, antispasmodics, drugs that regulate motor function of the intestine, and the means normalizing the composition of the intestinal bacterial flora. Most patients with symptomatic diverticulosis of the colon conservative treatment gives lasting effect.
• When diverticulitis shown antibiotics, intestinal antiseptic, means restoring normal intestinal microflora. With the development of bleeding diverticulum shown administering vasopressin through the catheter during selective angiography.
• When deciding on the need for surgical treatment are guided by the clinical picture and the combination of risk factors.
• Clinical management of diverticula of the duodenum.
• Treatment generally conservative directed to the prevention and cure of diverticulitis.
• With frequent recurrences of complications, a large scale diverticulum operative treatment. During the operation for detecting the air insufflation conducted diverticulum gavage, entered into the duodenum, or endoscopy is performed on the operating table. After detecting diverticulum produce its immersion and suturing intestine tunica muscularis defect.
• Tactics of treatment Meckel diverticulum.
• should not be removed asymptomatic diverticula.
• The presence of any clinical manifestations associated with diverticulum of the ileum, - indication for its removal.

Diverticular og Mekkel.

 Plan for future management of patients with diverticular bowel disease

It is necessary to carry out dispensary observation of the patient in Coloproctology.

When symptomatic diverticulosis with barium examination and colonoscopy is performed with a frequency of 1 every 3 years.

When resistant diverticulitis recurrence frequency are shown anti-treatment courses.

Prognosis

The prognosis of diverticular disease of the intestine, in most cases is favorable, but in some situations it can lead to severe and life-threatening complications. This can be explained not only by the severity of the complications themselves, but also a primary lesion of the elderly often have comorbidities, as well as lower in the body's resistance in this age group.

Symptomatic treatment diverticulosis colon with increased dietary fiber in the diet in some cases (5-10%) reduces the incidence of complications and improves its flow.

In 33% of patients relapse of the inflammatory process.

On average, 20% of patients with diverticulosis, complicated by bleeding, bleeding occurs again in a few months or years.

The prognosis of diverticula of the duodenum and Meckel's diverticulum - favorable.

prevention

Due to the fact that a diet with a limited content of fiber plant fibers predisposes to formation of diverticula, is to reduce the risk of colon diverticular disease in the diet is necessary to maintain a sufficient amount of fiber.