Diverticular disease of the colon. Colon diverticula

- these are saccular protrusions of the wall of the large, less often small intestine, of a congenital or acquired nature. The most common form of the disease is asymptomatic. Obvious clinical forms of pathology are manifested by vague abdominal pain, dyspeptic symptoms, and bleeding. For diagnosis, irrigography, colonoscopy, sigmoidoscopy, ultrasound and CT of the abdominal organs are used. Specific therapy includes the use of a diet with a high fiber content, the prescription of antispasmodics, prokinetics, antibacterial drugs, and lactulose. In case of complicated course of the disease, surgical treatment is required.

General information

Intestinal diverticula can be congenital (with hereditary pathology connective tissue) or acquired (associated with age-related weakness of interstitial fibers) nature. In the small intestine, diverticula are quite rare - in 1% of patients, while in most cases, Meckel's diverticulum is detected, containing tissue of the stomach or pancreas. Intestinal diverticula are often multiple and located in the left half of the colon (in 70% of cases).

IN at a young age Diverticulosis is detected only in 5% of cases, between the ages of 40 and 60 years - in 30% of the population, and after 80 years, the incidence of intestinal diverticula is more than 65%. Pathological protrusions can be complicated by inflammation, bleeding, perforation, but are almost never accompanied by malignancy. In recent years, there has been an increase in cases of diverticulosis in developed countries, which is associated with changes in dietary habits, exclusion of fiber and healthy dietary fiber from the diet.

Causes

Various factors can lead to the appearance of congenital and acquired intestinal diverticula, but they are all based on connective tissue weakness. With congenital connective tissue dysplasia, diverticula are usually multiple, located not only in the intestines, but also in other organs (stomach, bladder, etc.). In the first years of the disease, the wall of congenital diverticula is represented by all layers of the intestinal wall, but with age the muscle fibers atrophy.

The occurrence of acquired intestinal diverticula is facilitated by dietary errors (consumption of processed foods, irregular meals, exclusion of fiber, fresh fruits and vegetables from the diet), vitamin deficiencies, constant constipation, intestinal motility disorders, sedentary lifestyle, obesity. Any of the above reasons leads to an increase in intraintestinal pressure, prolapse of the mucous and submucosal layers of the intestine between muscle fibers, the formation cavity formation 3-5 cm in diameter.

Pathanatomy

In the small intestine, Meckel's diverticulum is most often found - a congenital incomplete fusion of the vitelline duct, due to which a finger-like protrusion forms on the intestinal wall approximately 50 cm from the bauhinium valve, connecting with the intestine with a wide anastomosis. Sometimes single diverticula form in the duodenum - near the papilla of Vater or in the duodenal bulb (most often this happens against the background of duodenal ulcer). Other localizations of small intestinal diverticulosis are quite rare.

In the large intestine, diverticula primarily form in the sigmoid and left half of the transverse colon. Most often, the formations are located in two rows, one on each side along the mesentery. Colon diverticula tend to progress with age - increased pressure in the intestine, stagnation of fecal contents have a pulsation (squeezing) effect, which causes more and more protrusions of the intestinal wall to appear.

Classification

There are congenital and acquired forms of intestinal diverticula. Congenital diverticulosis is often multiple, the protrusions are localized in various organs. Diverticula can also be a component of the congenital Senta triad, combined with diaphragmatic hernia and cholelithiasis.

Acquired diverticula form with age in almost 80% of the population. They can be traction (in case of adhesive disease), false (in the absence of muscle fibers in the wall of the protrusion), formed against the background of diseases and injuries of the intestine. Diverticula of the small and large intestines are distinguished by location. Along the course, asymptomatic, clinically obvious and complicated diverticula are distinguished.

Symptoms of intestinal diverticula

Diverticula in most cases do not appear at all long time, discovered by chance during examination for other diseases. Clinically obvious forms most often indicate the possibility of complications. The appearance of symptoms and complications in diverticulosis is associated with impaired motility of the intestinal wall, stagnation of intestinal contents, both in the intestine and in the protrusion cavity, and increased intraintestinal pressure. All these factors lead to increased bacterial contamination (more than 1 million cells per ml), the formation fecal stones, thinning of the intestinal wall at the passage of blood vessels.

Clinically, small intestinal diverticula manifest as vague abdominal pain and chronic diarrhea. Protrusions of the wall of the large intestine can also cause pain in the abdomen, more so in the left half, often associated with defecation and disappearing after it. The disease is characterized by stool instability - constipation constantly alternates with diarrhea and periods normal stool. Upon examination feces formed in the form of balls surrounded by mucus. Patients are concerned increased flatulence, abundant discharge of intestinal gases.

Complications

With prolonged stagnation of fecal contents in diverticula, irreversible changes intestinal wall, activated intestinal flora and diverticulitis occurs - one of the most common complications of this disease. A chronic inflammatory process can exist for a long time, causing frequent recurrent bleeding, local peritonitis with the formation of adhesions, fistulas connecting the intestinal cavity with the vagina, bladder, and skin. At adhesive disease sometimes intestinal obstruction occurs.

Severe inflammation in the cavity of the diverticulum can lead to perforation of its wall, the release of intestinal contents into abdominal cavity with the formation of an interintestinal abscess, and in severe cases - diffuse peritonitis. Perforation of an intestinal diverticulum is characterized by the clinic “ acute abdomen", which is very often confused with acute appendicitis. A diagnostic error is usually detected only during surgery, during which intestinal diverticula are found.

Diagnostics

It is quite difficult to suspect the presence of intestinal diverticula, since this disease does not have a specific clinical picture. Most often, protrusions are discovered by chance, while searching for the cause of anemia and excluding intestinal tumors. If diverticular disease is suspected, the gastroenterologist will prescribe a series of laboratory research: general analysis blood will determine inflammatory changes and anemia, a stool test for occult blood will help to detect intestinal bleeding in a timely manner, and a coprogram and bacteriological examination of stool will diagnose intestinal dysfunction, digestive disorders and increased bacterial contamination.

Patients with this disease require irrigography, preferably with double contrast. On x-ray protrusions of the intestinal wall communicating with the intestinal cavity will be visible. It should be remembered that in the presence of complications of intestinal diverticula, it is first necessary to take a survey x-ray of the abdominal organs, make sure there are no signs of perforation, and only then prescribe irrigography.

Treatment of intestinal diverticula

Treatment of patients with an uncomplicated form of diverticulosis is carried out in the gastroenterology department, and if it occurs severe complications- in a surgical hospital. Hospitalize patients with acute or exacerbation of chronic diverticulitis, intoxication, high fever, severe concomitant pathology, inability to enteral nutrition, and over the age of 85 years. If there is a clinic with an acute abdomen, an urgent operation is performed.

If a patient is accidentally diagnosed with an asymptomatic intestinal diverticulum, no special treatment is required. The patient is recommended to introduce a sufficient amount of fiber into the diet and adhere to the principles healthy eating. In the presence of uncomplicated diverticula, a diet rich in fiber, antispasmodics, and prokinetics are prescribed. If all recommendations for treatment of the disease are followed, stable clinical effect. If the patient has developed diverticulitis, the use of intestinal antiseptics, antibiotics, and osmotic laxatives is recommended.

To normalize intestinal function, cleansing enemas and uncontrolled use of laxatives should be abandoned. A positive effect is also achieved when moderate amounts are introduced into the daily routine. physical activity– they help strengthen the muscular corset of the torso and normalize intestinal motility. To reduce pressure in the intestinal lumen, a diet rich in fiber is prescribed (except for very coarse fibers - pineapples, persimmons, turnips, radishes). The amount of fiber in the diet is increased to 32 g/l. It is necessary to exclude gas-forming foods, legumes, and carbonated drinks. To achieve the desired effect, you should drink at least two liters of water daily.

The use of stimulant laxatives and morphine-based painkillers for diverticula is contraindicated, as they provoke further impairment of intestinal motility and aggravate the course of the disease. To improve the passage of food masses through the intestines, osmotic laxatives are prescribed - they increase the volume of feces and accelerate their movement through the intestines. digestive tract. For diarrhea, sorbents and astringents are prescribed, and simethicone preparations are prescribed to relieve flatulence.

Acute diverticulitis requires hospitalization of the patient in a surgical hospital, the appointment of detoxification and plasma replacement agents, and antibacterial drugs. Treatment lasts at least two to three weeks; after discharge from the hospital, maintenance therapy is similar to that carried out for uncomplicated diverticula.

Surgical treatment is indicated for the development of life-threatening complications: perforation, abscess formation, intestinal obstruction, profuse bleeding, fistula formation. Also elective surgery prescribed for recurrent bleeding and diverticulitis. Usually, a part of the intestine affected by diverticulosis is resected and an anastomosis is performed. IN difficult situations A colostomy is performed to facilitate the outflow of feces, and after stabilization of the condition, reconstructive surgery is performed.

Prognosis and prevention

The prognosis for intestinal diverticula is usually favorable, but sometimes this disease leads to the development of life-threatening complications. Diverticulitis occurs in about a quarter of patients. The effectiveness of its treatment during the first episode is the highest - up to 70%; during the third episode, the effectiveness of therapy decreases to 6%. There is no prevention for congenital intestinal diverticula. The development of acquired diverticula can be prevented by normalizing the diet, consuming enough fiber and fluid, and using moderate physical activity.

Colon diverticula are limited pouch-like protrusions of the intestinal wall. Colon diverticulosis is a condition characterized by the presence of many diverticula scattered throughout the colon or concentrated in one area. Diverticular disease of the colon is a collective concept that includes clinical manifestations both uncomplicated and complicated diverticula.

Prevalence. Colon diverticulosis occurs in 17 people per 100 thousand population. During X-ray examination, diverticula are diagnosed in 24-30% of people. They are detected 1.2-1.5 times more often in women. Diverticula are mainly observed at the age of 50-60 years.

Etiology and pathogenesis. Diverticula of the colon appear as a result of a violation of embryogenesis (congenital diverticula) or during a person’s life (acquired diverticula). The pathogenesis of the disease has not been fully studied. There are several different theories of the occurrence of acquired diverticula of the colon: the theory of congenital predisposition, vascular, mesenchymal, mechanical (pulsion or hernial).

The most common is the hernia theory (Drummoud, 1917), which explains the development of diverticula by a weakening of the connective tissue apparatus of the intestinal wall and an increase in intra-abdominal pressure. Weak areas in the intestinal wall are the passage of blood and lymphatic vessels.

However, it was later established (Morson, 1962; Painter, 1964) that the appearance of diverticula may be associated with discoordination of contractions of the longitudinal and circular muscle layers due to intra- and extra-intestinal changes in the nervous system. This leads to segmental spasm of the muscle membrane and sharp increase pressure in certain areas of the intestine. Hypertension is accompanied by protrusion of the mucous layer at the points of penetration of blood vessels into the muscle wall and working muscle hypertrophy.

Pathological anatomy. Diverticula look like limited protrusions of the intestinal wall various shapes, the diameter of which is about 1 cm. These are the so-called complete, extramural or marginal diverticula. Through a narrow neck (diameter 1.5-2 mm) they communicate with the intestinal lumen. However, in 0.5-1% of cases, diverticula are located between the layers of the intestinal wall (intramural, incomplete, dissecting diverticula). Congenital diverticula are true, that is, they have a structure identical to the structure of the intestinal wall. Acquired diverticula are false. Their wall is represented only by the mucous membrane. At the beginning of the disease, the mucous membrane is not changed, then it undergoes ulceration and rejection with bleeding, perforation or replacement with granulation tissue. At the same time, inflammatory changes develop in the visceral peritoneum covering the diverticulum, which leads to the formation of adhesions in the abdominal cavity. In 80-95% of cases, diverticulosis affects the sigmoid colon.

Classification. The following clinical forms of diverticulosis (diverticula) of the colon are distinguished: 1) diverticulosis (diverticulum) without manifestations; 2) diverticulosis (diverticulum) with pronounced clinical manifestations (uncomplicated); 3) diverticulosis (diverticulum) with a complicated course: a) diverticulitis (acute and chronic); b) perforation (into the free abdominal cavity or covered); c) bleeding; G) ; e) (external and internal); e) cancer (cancer due to diverticula).

Clinical picture. Main clinical symptoms Colon diverticula are in the abdomen and intestinal dysfunction.

The pain is constant, intensifies after eating, constipation, decreases after defecation. It is characterized by a variety of localizations. Pain syndrome is most often detected in the left iliac region and above the pubis, that is, in the projection of the sigmoid colon. The origin of the pain is associated with intestinal spasm and increased intraperitoneal pressure.

Intestinal dysfunction is manifested by constipation, sometimes diarrhea, and unstable stool. In some cases, patients experience nausea and vomiting.

More diverse clinical picture observed in the case of a combination of colon diverticula with diaphragmatic hernia And cholelithiasis(Saint's triad, occurs in 1% of cases), peptic ulcer stomach or duodenum, diabetes mellitus.

Complications of diverticulosis are manifested by their clinical symptoms. Diverticulitis occurs in 30–90% of patients. According to the nature of the course, acute and chronic diverticulitis are divided. Acute diverticulitis occurs rarely and mainly in true diverticula. It is accompanied by fairly intense abdominal pain, increased body temperature, leukocytosis, and an increase in ESR. When surrounding tissues are involved in the inflammatory process, symptoms of peritoneal irritation are determined. In the projection of the colon, an infiltrate prone to chronicity is found by palpation. Quite often it festeres. The resulting abscess can empty into the free abdominal cavity with the development of peritonitis, into the bladder, into jejunum etc. with the formation of internal fistulas (in 8-12% of cases). Resorption of the infiltrate and subsequent attacks of inflammation lead to thickening of the intestinal wall and its mesentery, i.e., to a pseudotumor of the intestine.

There are three types of chronic diverticulitis: latent, colitis-like and in the form of “abdominal crises”.

In the latent variant, chronic diverticulitis occurs over a long period of time without obvious clinical symptoms. However, occasionally patients experience attacks of abdominal pain, stool disturbances, and flatulence. The colitis-like variant is characterized by more frequent attacks pain, severe constipation or diarrhea. An admixture of mucus and blood often appears in the stool. Body temperature periodically rises. For the variant of chronic diverticulitis, which occurs in the form of “abdominal crises,” the presence of attacks of abdominal pain similar to acute ones is typical. surgical disease abdominal organs. The pain is local at first, but then it becomes widespread. Patients' body temperature rises. Chills are often observed. Against this background, diarrhea appears or flatulence occurs. The stool contains mucus, blood, and sometimes pus. The affected area of ​​the intestine is sharply painful on palpation. In some cases, symptoms of peritoneal irritation are detected.

Perforation of diverticula occurs in 30-40% of cases, which is manifested by severe fecal peritonitis.

Intestinal bleeding is the most common complication of diverticulosis (45-70% of cases). Usually it is moderate, but is often profuse in nature. In some patients, the presence of blood in the stool may be the main sign of diverticulosis in the case of an asymptomatic course of the disease. When the diverticulum is located in the distal colon, the blood released is scarlet. Undiagnosed, unnoticed bleeding leads to anemia in patients.

Intestinal obstruction is observed in 0.5-10% of cases. More often it is obstructive, which is associated with the presence of intestinal pseudotumors.

Chronic diverticulitis often leads to the development of perivisceritis, which is facilitated by thin wall false diverticulum.

More rare complications of diverticular disease include purulent phlebitis of the portal vein and its branches with the formation of abscesses in the liver, lungs, and brain; sepsis; diverticulum torsion.

Diagnosis of colon diverticula. In recognizing diverticular disease, in addition to clinical data, the results of radiopaque (irrigography), endoscopic studies (sigmoidoscopy,), computed tomography, and large intestine are used.

On radiographs taken during tight filling of the colon with an aqueous suspension of barium sulfate, diverticula have the appearance of single or multiple round-oval bulges of the wall with a smooth, clear contour 0.3-1.5 cm in diameter. Uncomplicated diverticula drain well. Haustration and relief of the intestinal mucosa are not changed. The contours of inflamed diverticula are deformed, unclear, jagged. The contrast mass lingers in them for a long time (for 2 or more days). The affected areas of the colon are spasmed, the haustra and the relief of the mucous membrane are deformed.

Endoscopic examination allows not only to identify diverticula, but also to differential diagnosis, clarify the localization of the source of intestinal bleeding, and carry out local hemostasis.

Computed tomography for colon diverticula is more often used in acute stage to assess the condition of the intestinal wall and peri-intestinal tissues.

Ultrasound is a less reliable method for diagnosing diverticula, since it reveals diverticula only when they are well filled.

Differential diagnosis. Diverticula and diverticulum are clear diseases of the colon and are differentiated from Crohn's disease, ulcerative colitis, polyposis and colon cancer, proctosigmoiditis.

Treatment of colon diverticula. For diverticula and diverticular disease of the colon, differentiated treatment is carried out. Thus, patients with diverticulum (diverticula) without clinical manifestations are subject to dispensary observation with comprehensive prevention progression of the disease.

They are prescribed a diet enriched with dietary fiber. Foods that cause bloating (legumes, grapes) and (blueberries, rice) are excluded from the diet. In patients with uncomplicated diverticula with pronounced clinical manifestations, complex therapy is carried out.

It includes, first of all, a special diet taking into account the nature of the stool. To relieve constipation, foods and medications, absorbing water, increasing in volume, which leads to irritation of intestinal receptors (sea kale, flax-seed, plantain seeds, mucofalk, sterculin, methyl cellulose, gutalax and others in an individually selected dose). Gas-forming vegetables and whole milk are not recommended. For patients with diarrhea, the consumption of fiber is limited, astringents and adsorbents are prescribed (white clay, smecta, carbolene, calcium carbonate, bismuth preparations). The complex of drug treatment includes: 1) antispasmodics (no-spa, papaverine, baralgin, etc.) and holy policies (platifillin, atropine, metacin, etc.) - with severe movement disorders colon; 2) broad-spectrum antibiotics (ampicillin, tetracycline, gentamicin, ciprofloxacin, etc.), and after examining stool - taking into account the microflora and its sensitivity to antibacterial drugs; according to indications, courses of treatment are carried out with metronidazole, nitrofuran drugs, nicodine, intetrix; 3) desensitizing agents (suprastin, tavegil, etc.); 4) vitamins (B1, B6, B12, multivitamins with microelements, etc.); 5) sedatives, psychotropic drugs, psychotherapy - for anxiety and depression of patients; b) physiotherapeutic treatment.

When severe course diverticular disease in the first 1-3 days is carried out parenteral nutrition, detoxification therapy, the deficiency of fluid and electrolytes is compensated. Patients are prescribed bed rest.

Surgical intervention is indicated in case of failure of drug treatment of uncomplicated diverticular disease, as well as in case of complications of diverticulosis: a) profuse bleeding that does not stop under the influence of conservative measures or is often repeated; b) perforation; c) chronic diverticular infiltrate; d) suppuration of the diverticulum; e) internal fistulas; f) intestinal obstruction; g) cancer. However, recently there has been a tendency towards more active surgical treatment of patients with uncomplicated diverticulosis, which is explained by the high mortality rate of complications of the disease (reaching 40-70%).

The scope of surgical intervention in each specific case is determined individually depending on the extent of the process, the nature of existing complications, the condition of the intestinal wall and surrounding tissues, concomitant diseases. The choice is resection of the entire segment of the colon containing diverticula, with the imposition of a primary anastomosis using one of the options from an open approach or laparoscopically.

In patients with diverticulitis, planned resection is performed after 6-12 months. after relief of inflammation. To protect the anastomosis, if there is doubt about its reliability, a proximal unloading colostomy is performed. If the operation is performed under conditions that do not allow the formation of an interintestinal anastomosis (peritonitis, perifocal inflammation, etc.), the affected area of ​​the intestine is resected and a double- or single-barrel colostomy is performed. The integrity of the intestinal tube is restored after inflammation subsides after 3-6 months. For diverticula complicated by a limited abscess, a primary anastomosis is performed if the anastomosed areas of the intestine are not inflammatory. Otherwise, a resection of the colon is performed, a colostomy is performed, and the abscess cavity is drained. Subsequently, the patient is subject to repeated reconstructive surgery.

Obvious symptoms in most patients with colon diverticulosis (diverticular disease) are absent or identical to those of other intestinal diseases. But it has been found that the incidence of diverticulosis increases with increasing age. It is less than 10% among people under 40 years of age and about 50 - 60% over 80. On the European continent, diverticula are diagnosed in every 10th inhabitant before the age of 40, after 60 years - in every third, and from 75 years - every second resident .

Symptoms of intestinal diverticulosis are related to the location of the diverticula. Among the population Western countries most often, in 90% of reported cases, they are found in the distal parts of the colon, of which 50–60% are in the sigmoid colon and only 10% are in the right parts of the colon. The localization of diverticula in the rectum was not detected.

The main mechanisms of symptoms

The predominant frequency of sigmoid colon diverticula and corresponding symptoms are associated with anatomical and physiological characteristics. The sigmoid colon has a smaller diameter and more bends than the rest of the large intestine. It performs the function of a reservoir in which the formation, compaction and accumulation of feces occurs. By regulating their movement into the rectum, it is segmented much more often than other sections. All these reasons lead to high blood pressure and stretching of the walls of the sigmoid colon.

The occurrence of diverticula is promoted by age-related changes connective tissue and muscle fibers of the transverse colon. As a result of this, there is an increasing increase muscle tension and resistance to the movement of feces, intraintestinal pressure and protrusion of the mucous membrane through defects in the muscular layer of the intestinal wall.

At the same time there are pathological changes and submucosal nerve plexuses with dysfunction of baroreceptors, thickening of the circular and longitudinal layers of the muscular lining of the intestine, decreased extensibility and tone of its walls, convergence of the circular folds, as a result of which the intestine takes on the appearance of an accordion. This in turn leads mainly to:

• compression of blood vessels located in the intestinal wall;
• deterioration of blood microcirculation and the development of ischemia;
• atrophy of the muscle layer;
• impaired intestinal motility;
• the formation of weak areas on which diverticula form.

Clinical manifestations of diverticulosis of the large intestine, sigmoid colon

All of these changes cause dysfunction of the intestine as a whole with the gradual development of symptoms of diverticulosis of the large intestine and its complications:

• Diverticulitis (inflammation of diverticulum)
• Bleeding
• Perforation (perforation)
• Formation of infiltrate
• Fistulas internal or external (rare)
• Acute or chronic intestinal obstruction

The disease is mainly progressive in nature with clinical manifestations, the severity of which depends on the duration of the disease, complications of diverticular disease, localization of diverticula, the presence of concomitant diseases, the age of the patient and his compliance with recommendations regarding proper nutrition.

Most common clinical form- This is uncomplicated diverticulosis of the large intestine. It occurs in almost 80% of patients with this disease. For many years it was believed that such forms of the disease proceed completely in the absence of symptoms. But research recent years showed that in 85% of patients, even single diverticula of the colon, not to mention diverticulosis, are accompanied by clinical manifestations of varying severity.

However, the symptoms are nonspecific. Often patients either do not seek treatment medical care in general, or, if they did go to the doctor, they are given diagnoses such as dysbacteriosis, chronic colitis, dyskinesia of the large intestine, etc.

The most common and main symptoms of uncomplicated diverticulosis of the large intestine:

• Intermittent recurring pain of a spastic, paroxysmal or dull aching nature in the left (most often), middle (below the navel) or lower parts belly. It is assumed that these pains arise as a result of increased pressure in the intestinal lumen and impaired motility.
• The pain may go away on its own after a few hours, but may intensify, especially after eating.
• Pain similar to an attack of appendicitis may occur (in the right lower abdomen), even if the diverticula are not localized in the ascending sections (right), but in the sigmoid colon (left).
• Sometimes there is irradiation (spread) of pain: in the area anus, lower back, sacrum, as well as in the groin or buttock areas.
• Relief or complete disappearance of pain after passing gas or defecation.

In addition to the main manifestations of diverticulosis of the large intestine, there may be general symptoms, characteristic of a violation of its function:

• constipation that is persistent;
• constipation followed by diarrhea;
• secretion of copious amounts of mucus;
• bloating and significant discharge of foul-smelling gases;
• false urges (tenesmus) or repeated acts of defecation;
• a feeling of incomplete emptying after defecation (often accompanies the presence of diverticula in the sigmoid colon).

Upon examination, the doctor notes bloating and pain on palpation (palpation) along the entire large intestine. These phenomena are most pronounced in the left sections, but at the same time defensive reaction(voltage) abdominal wall absent. The spasmodic part of the colon, in which diverticula are localized, is also palpated.

Some features diverticulosis various departments transverse colon:

When complications arise in the form of diverticulitis, bleeding, perforation, and so on, the corresponding symptoms arise:

• with changes clinical tests blood, urine
• the appearance of temperature
• blood in stool
• change in character pain syndrome etc.

Diagnosis using basic instrumental methods, such as irrigography ( X-ray examination after the intestines are full contrast agent), endoscopy, CT scan, allows you to more accurately determine the presence, location and condition of diverticula.

Treatment of uncomplicated diverticulosis

The main thing in the treatment of intestinal diverticulosis (uncomplicated form) is to eat foods rich in dietary fiber. According to the latest data, their use by patients with asymptomatic disease helps prevent its progression and complications. There is a conflicting opinion among some researchers that the inclusion of these products in the diet even leads to regression of diverticula.

Dietary, or dietary fiber, is plant fibrous substances of various composition and structure that are not digested or absorbed in the intestines. With a daily caloric intake of 2500 kcal physiological need they contain 30 g. Most of types of plant fiber contains indigestible polysaccharides, pectin, cellulose and hemicellulose, lignin, alginates. Their main property is the binding of water in the intestinal lumen, which increases the volume of chyme, reduces pressure inside the intestine and promotes faster transport through the intestines and the removal of feces and toxins from the body.

In addition, insoluble dietary fiber, which covers about 6–9% of the body’s energy needs, creates a large additional surface area in the colon on which placement and fixation occurs. large number useful intestinal bacteria. Fibers provide a breeding ground for “friendly” bacteria, on which they quickly grow and multiply, which leads to the suppression of pathogenic flora.

Table describing the positive effect of dietary fiber on the human body:

It becomes clear why dietary products containing bran are an effective diet for intestinal diverticulosis. The greatest ability to reduce intraintestinal pressure and increase the volume of chyme has wheat bran coarse grind. They must be introduced into the diet gradually over a period of 2 weeks to 1 month. Daily norm starts from 5 - 10 g to 20 - 30 g. For this purpose, the daily dose (2 - 4 tablespoons) of bran is poured with 1 glass of boiling water and left for 30 - 40 minutes, after which the water must be drained. Brewed bran can be added to vegetable dishes, dairy products, porridge, soups.

During the first month of such a diet for intestinal diverticulosis, containing a large number of vegetable dietary fiber, abdominal pain may appear or intensify. Therefore, it is recommended to take antispasmodic drugs, for example, no-shpa or mebeverine 20 - 30 minutes before meals in the morning and evening, 400 mg, meteospasmil, bucopan and others.

Mucofalk, Fiberlex, Ispagol, Solgar Psyllium preparations, consisting of the seed shells of plantain oval, which grows in the arid regions of the Mediterranean, Pakistan and India, are considered an effective source of dietary fiber. The shell of plantain seeds of this particular species contains high concentrations of mucous components, making the drug a soft dietary fiber.

Mucofalk, unlike bran, has almost no side effects in the form of flatulence and spastic pain, but it has an anti-inflammatory effect and is significantly superior to wheat bran in reducing intraintestinal pressure, and effectively promotes the proliferation of lacto- and bifidobacteria.

The dietary fiber that makes up Mucofalk has the following physicochemical characteristics:

• Slow down the process of evacuation of food mass from the stomach
• Increases the viscosity of food masses in the small intestine
• Increase the formation of mucus on the cells of the mucous membrane of the large intestine
• They bind and retain a volume of water exceeding the mass of the fibers themselves, thereby reducing the tension of the intestinal walls, moisturizing feces and ensuring their accelerated passage through the intestines.
• Collect and retain toxic elements of external and internal origin on their surface in a colloidal state
• They provide additional area for useful microbial associations and, undergoing enzymatic decomposition by microorganisms, become an energy resource for the latter
• Do not impede the absorption of microelements and vitamins in the intestines

It is recommended to include in the diet of patients with intestinal diverticulosis:

• bread made from bran or wholemeal white flour
• crumbly porridge from wheat and buckwheat with vegetable oil
• vegetable casseroles
• vegetable soups with meat broth
• dairy products
• baked vegetables (if tolerated)

It is advisable to exclude from the diet astringents and inhibitors of peristalsis. food products. These include:

• bread made from finely ground premium flour
• pasta
• semolina and rice porridge
• jelly, coffee and strong brewed tea
• red wine, cocoa and chocolate

Dietary fiber is the main means of treating and preventing diverticulosis of the large intestine. In the absence of complicated forms of the disease, their constant use is recommended, with the exception of the summer and autumn seasons, due to the inclusion of a sufficient amount of fresh vegetables, fruits and herbs in the diet.

Drug treatment

For intestinal diverticulosis, treatment tactics are determined general condition the patient’s health, the severity of the disease, the presence of complications.

For asymptomatic diverticulosis

when the disease was diagnosed by chance (accidental finding), the patient is recommended to follow a diet only, with an increase in the daily diet of fruits, vegetables, beans, grains, and consumption of at least 2 liters of fluid per day (if there are no contraindications). According to indications, it is possible to use probiotics (see), enzyme preparations, medicines, reducing).

In the presence of uncomplicated inflammatory process

With the development of the inflammatory process and symptoms of intestinal diverticulosis, but without serious complications, outpatient treatment is possible. In addition to the diet described above with maximum number fiber and drinking regimen are prescribed:

If the disease progresses during treatment, hospitalization is indicated

If there is no improvement within 3 days of therapy, then the patient is indicated for hospitalization, with correction of treatment and determination of further treatment tactics. Produced additional diagnostics, is appointed infusion therapy- glucose solution, saline solutions, the issue of surgical treatment is being decided.

When is surgery indicated?

If the patient has had 2 attacks of diverticulosis, according to the latest clinical studies, elective surgery is advisable. Since repeated attacks are poorly amenable to drug treatment and, as a rule, end in intestinal perforation followed by peritonitis. Moreover, in patients over 40 years of age, even after 1 episode of diverticulitis, surgical treatment is recommended.

Surgical treatment consists of removing (resection) the part of the intestine that is affected by diverticula. Indications for surgery are the following complications:

• heavy bleeding
• progressive intestinal obstruction
• perforation of the diverticulum with the development of peritonitis or retroperitoneal phlegmon
• opening of an abscess when external or internal intestinal fistulas develop

In each specific clinical case The scope of the operation is determined individually; sometimes during emergency surgery, the intestine is removed in an unnatural way onto the abdominal wall. Timely appeal patient to a gastroenterologist and coloproctologist, adequate therapy and planned surgical treatment (especially after an attack) improve the prognosis. In 80% of cases, diverticulosis occurs without complications; in case of complications, the risk of relapse in the future is 25%.

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You can often hear names of intestinal diseases that indicate inflammation, for example, colitis, or “nonspecific ulcerative colitis.” – this is inflammation vermiform appendix. What do such “unusual” endings to disease names as “polyposis” or “diverticulosis” indicate?

IN Latin such an ending characterizes “wealth” of something, or more precisely, the proliferation of tissue or formation. Therefore, “polyposis” is the formation of polyps, for example, on the intestinal mucosa, and what is diverticulosis?

Intestinal diverticulosis - what is it?

A diverticulum can only occur in a hollow organ, such as the esophagus or intestine. This is the name given to the protrusion of the wall of a hollow organ, which resembles a small sac. In principle, a regular hernia, inguinal or femoral, can also be considered a diverticulum of the anterior abdominal wall, which “came out” through a weak spot.

Intestinal diverticulosis (diverticular disease) is the process of formation of pouch-like pockets and protrusions in the wall of the large intestine.

It is no coincidence that the disease is called “diverticulosis” and not “diverticulitis”. This means that initially there is no inflammatory component.

But then inflammation occurs, which causes clinical manifestations. Why do diverticula occur in the intestinal wall?

Reasons for the development of diverticula

In order for a diverticulum to appear, two factors must occur:

• decreased elasticity of the colon wall (predisposing factor);
• The pressure inside the intestine in this area (producing factor) increased sharply.

Both of these reasons are common. A decrease in elasticity occurs with aging of the body, with habitual overstretching of the intestines. It occurs due to decreased peristalsis and stagnation of feces. Most often, this is caused by a diet depleted in fiber, physical inactivity and increased consumption of flour and meat products.

Therefore, this disease often occurs in residents of large cities, in northern countries, busy mental labor. In the event that a person does not have overweight, moves a lot and eats vegetable and dairy foods, then he is not afraid of such a disease.

The producing factor occurs with habitual constipation, with uncontrolled use laxatives. In more rare cases, the immediate cause is dysentery, which contributes to the appearance of tenesmus or false urge to defecate.

Diverticula can be false or true. Diverticulosis is the spread of false diverticula, in which the protrusion does not affect all the walls of the intestine, but only the mucous and submucosal layers.

Of course, a hernia formed under the skin is visible, but how does intestinal diverticulosis manifest?

Almost always this disease is asymptomatic until complications develop. And if symptoms do appear, then, basically, they are nonspecific, that is, they can occur when various diseases, and not only when diverticula appear. Thus, complaints include:

1) Abdominal pain, which often occurs on the left, often in the iliac region, in the projection of the descending colon and sigmoid colon. The pain is due to the fact that the accumulating stool puts pressure on the defective walls of the diverticulum. Also, a pronounced accumulation of gases leads to the appearance of pain.

Characteristic, perhaps, is the weakening or complete disappearance of pain after bowel movement. Such pain can appear several times a year. In this case, they indicate an exacerbation of a chronic process, or the appearance of new diverticula.

2) Bowel disorders usually look like normal, habitual constipation. Sometimes constipation is replaced by periods of increased intestinal motility and diarrhea occurs. Such periods of unstable stool with diverticulosis also occur during exacerbation of the disease.

Additional signs of this disease include a feeling of incomplete bowel movement during bowel movements, but this is again nonspecific and can occur with many diseases of the anorectal area, for example, with tumors.

Such a “hidden” course often leads to the fact that this diagnosis is finally established only during complications, when urgent surgery is required.

What complications accompany intestinal diverticulosis?

The most common complications include:

• diverticulitis

This is a condition when the saccular formation begins to become inflamed. It is, most often, with diverticulitis that clinical symptoms begin, which are manifested by pain and stool disorders. If the inflammation progresses, it can simulate both acute appendicitis and perforated ulcer. The temperature rises, and leukocytosis occurs in the blood.

• peritonitis

Develops due to perforation of a diverticulum into the abdominal cavity. It occurs more often against the background of diverticulitis, but can occur without any preliminary symptoms.

• phlegmon

In the event that the fecal contents do not enter the abdominal cavity, but into the retroperitoneal tissue, where the abdominal aorta passes, then a spill occurs purulent inflammation this fiber, or phlegmon. Its danger is that it has no anatomical boundaries and can spread retroperitoneally anywhere.

• If the diverticulum breaks between the layers of the mesentery, an abscess will occur, which is called paracolic.

By at least, for some time the mesenteries will restrain inflammation and prevent peritonitis, but this may be fraught with necrosis of part of the intestine.

• intestinal bleeding

Since the source of blood is located close to anus, then the blood is not processed in the intestines and comes out in the form of clots or fresh.

Typically, most diverticula are located on the left side of the colon, but bleeding occurs in 80% of cases if the protrusion is located on the right.

With massive bleeding, signs of collapse occur (pallor, weakness, dizziness, ringing in the ears, fainting, cold sweat, rapid and weak pulse). With continued bleeding, hemorrhagic shock occurs.

• signs intestinal obstruction;
• abscesses that form inside a diverticulum.

If such an abscess breaks into the intestine, then improvement, or even recovery, occurs, since the pus literally pours out into the feces. It is much worse if the abscess breaks into the abdominal cavity with the development of peritonitis, or penetration occurs into a hollow organ (adjacent loops, bladder or vagina), then fistulas are formed.

As you can see, diverticulosis is a dangerous time bomb. How can this disease be treated so as not to lead to complications? To do this, you need to diagnose it without waiting for an emergency: after all, the mortality rate when contacting in the event of a complication developing is 20%. How can you make a diagnosis?

Diagnosis of intestinal diverticulosis

Here we will talk about routine diagnostics. The most reliable methods are:

1. Irrigoscopy with contrast. You can see various protrusions that are located behind the contour of the intestine, especially after bowel movement and inflating the intestine with air;
2. Colonoscopy. In this case, the colonoscope has difficulty moving through the affected area, since there is intestinal spasm in this place.

Of course, medical history and the presence of predisposing factors are also important. The whole problem with the lack of routine diagnostics comes down to the fact that the patient simply does not want to undergo “unpleasant” procedures, such as colonoscopy and irrigoscopy.

As a result, diagnosis is carried out during emergency care at intestinal bleeding or during surgery for peritonitis.

Treatment of diverticulosis - diet, medications and surgery

Treatment of diverticulosis of the large intestine should begin as planned - the basis of therapy is proper, therapeutic nutrition.

Diet

Nutrition for intestinal diverticulosis should be such as to eliminate constipation and stimulate motility. To do this, use fermented milk dishes, rich vegetable fiber, fruits, vegetables.

It is important that you can start eating fiber-rich foods only during the period complete remission. If there are signs of inflammation, that is, diverticulitis, then you need to wait with fiber, since excessive stimulation of motor skills with rough food can lead to additional complication or diverticulum rupture.

You need to exclude pickles, smoked meats, hot sauces, fatty foods, flour products, as well as coarse cereals, such as pearl barley, from your diet. Carbonated drinks are prohibited, as well as those fruits that increase fermentative dyspepsia and cause the formation of excess gas.

Drug therapy, drugs

The basis of drug therapy should be to prevent the creation of high pressure. For this purpose the following are assigned:

• myotropic antispasmodics (papaverine, No-Shpa);
• eubiotics that improve the environment in the intestines (Linex, Baktisubtil);
• prokinetics (Motilium).

They try to normalize stool without using laxatives, so as not to increase the pressure inside the intestine. At the same time, it is not forbidden to increase pressure outside the intestine, so such means of normalizing stool as swimming, cycling or dancing are welcome.

An exception, perhaps, can only be made for Duphalac or Lactulose, which is prescribed 30 ml daily.

Treatment of intestinal diverticulosis in the event of a rise in temperature and the appearance of complaints is carried out in a hospital, using antibacterial therapy. The main goal is to prevent complications.

Surgical treatment

As a rule, operations for this disease are performed only emergency indications and for complications. Most often, a resection of the affected area of ​​the intestine is performed, for example, a hemicolectomy.

Also, almost a third of all patients with bleeding are operated on, and in the same way, resection is performed, and to reduce the pressure the muscular layer is cut, that is, myotomy is performed, since no one performs removal, or plastic surgery of multiple diverticula.

Treatment prognosis

With this disease, the prognosis depends entirely on timely diagnosis, making a diagnosis in the “cold” period of the disease and successful conservative treatment, followed by control irrigoscopy and colonoscopy. Otherwise, the disease will manifest itself as complications.

You can do a simple calculation. If diverticulosis occurs in 8% of the adult population, and 5% of cases manifest themselves with bleeding, and 20% with the development of diverticulitis and other complications, then it turns out that in 25% of cases, the process manifests itself as a complication.

In other words, 2% of the population, or one in 50 people, is at risk of being hospitalized.

Prevention of colon diverticulosis

Intestinal diverticulosis, the symptoms and treatment of which we have examined, is a disease of “civilization.” The basic principles of prevention are as follows:

• physical activity;
• preventing excess weight gain;
• consumption of fiber, fluids, dairy and plant food, vegetable oils;
• limiting bakery, meat and refined products;
• developing the habit of regular bowel movements.

Following these simple measures will allow you to avoid many diseases and achieve healthy and fulfilling longevity.

Diverticulosis of the colon. Clinic. Diagnostics. Treatment
Diverticulosis of the colon is divided into congenital and acquired.

Congenital diverticula develop due to a violation of histogenesis during embryonic development.

Acquired diverticula occur as a result of protrusion of the mucous membrane through defects in the muscularis propria.

Most often, diverticula are localized at places where blood vessels enter the intestinal wall, as well as between longitudinal muscle bands, where muscle layer colon is less pronounced. The reasons contributing to the occurrence of diverticula are inflammatory processes in the intestine, increased intraluminal pressure (with constipation), age-related dystrophic changes connective tissue and muscle elements of the intestinal wall.

Diverticula most often occur in the sigmoid colon and the left half of the colon.

As the diverticulum enlarges, its wall becomes thinner and the mucous membrane atrophies. Stagnation of feces in a diverticulum entails the formation of erosions, ulcers, and the development of an inflammatory process (diverticulitis).

Clinical manifestations of diverticulosis are missing. With the development of diverticulitis, pain in the lower abdomen, unstable stools, decreased appetite, nausea, and sometimes vomiting appear. Severe inflammation is accompanied by low-grade fever and leukocytosis. Palpation of the abdomen in the affected area causes sharp pain, there is moderate muscle tension.

Clinical picture very similar to that of acute appendicitis, but all the symptoms appear on the left. Against the background of diverticulitis, perforation of the diverticulum into the free abdominal cavity may occur with the development of peritonitis. When perforation occurs in the retroperitoneal tissue, phlegmon develops.

Another complication of diverticulitis is the formation of abscesses in the closed cavity of the diverticulum. Breakthrough of the diverticulum into the intestine leads to recovery. When an abscess breaks into the abdominal cavity, peritonitis develops, and into a hollow organ - an internal fistula.

Long-term diverticulitis leads to the occurrence of adhesions, as a result of which intestinal obstruction often develops.

Sometimes, due to erosion of the arterial trunk located at the neck of the diverticulum, bleeding occurs.

Diagnosis of diverticulosis based on medical history, results of X-ray and colonoscopic examinations. However, in diverticulitis, performing these studies is dangerous due to the possibility of perforation of the diverticulum. In case of bleeding, irrigoscopy can also be used as a therapeutic method, providing barium tamponing of the diverticulum cavity with a bleeding section.

Treatment of diverticulosis predominantly conservative and aimed at normalizing stool and relieving spastic and inflammatory changes in the colon. In this regard, the patient is prescribed a diet, antispasmodics, antibiotics, sulfonamides, enemas with antiseptic solutions. Indications for surgical treatment are perforation of the diverticulum, development of intestinal obstruction, internal fistulas, massive bleeding, severe diverticulitis with frequent exacerbations if ineffective conservative treatment. In case of diverticulitis of the colon, the affected part of the intestine is removed (hemicolectomy, resection of the sigmoid colon).