The diverticulitis is a disease of the large intestine , in which protuberances in the mucosa ( diverticulum forms) inflammation. The frequent occurrence of such protuberances is called diverticulosis and represents the preliminary stage of diverticulitis. The sigmoid colon is most frequently affected, i.e. in 95 percent of cases ( sigmoid diverticulitis - also known as "left side appendicitis"). Diverticulitis can occur in one percent of the transverse colon and two percent each in the caecum and in the ascending colon . As a rule, the sigmoid diverticula are so-called pseudodiverticula, i. H. the intestinal mucous membrane turns inside out through gaps in the muscular wall.
The formation of diverticula in the large intestine is common in western industrialized countries. Their frequency increases with age. It is rare in under 40-year-olds, around 30 percent in 60-year-olds and around 65 percent in 85-year-olds. About 12 to 25 percent of all people whose intestines have developed diverticula develop diverticulitis.
Risk factors are a low-fiber diet (according to one study, however, the opposite applies) and a lack of physical activity or obesity . Increased consumption of red (especially unprocessed) meat also increases the risk; this does not apply if poultry or fish are consumed instead. A vegetarian diet significantly lowers the risk of developing diverticulitis. Smoking and non-steroidal anti-inflammatory drugs are also considered risk factors.
Since diverticula are filled with feces, the thickening of the diverticulum can lead to the development of so-called fecal stones . This can lead to pressure necrosis of the mucous membrane in the diverticulum, which in turn results in inflammation of the diverticulum mucosa. The inflammation spreads to the surrounding area, so that, depending on the direction of spread, there may be accumulations of pus ( abscesses ) in the fatty tissue or it may spread to surrounding organs. This can lead to fistula formation in the large intestine with other intestinal regions, the urinary bladder or the vagina. At the rapid pace of the inflammatory process, as can be the case in very old people or in patients treated with anti-inflammatory drugs, an acutely life-threatening free peritonitis ( peritonitis ) results . In the case of long-term courses, the inflammation-related thickening of the intestinal wall leads to the narrowing of the clearing, which can result in an incomplete ( subileus or chronic ileus) or complete disruption of the intestinal passage , which is known as intestinal obstruction (or ileus ).
Symptoms and Diagnosis
The symptoms are sudden pain over the affected section of the intestine, most often in the left lower abdomen (hence also left side appendicitis ), often radiating to the back and with peritonitis limited to this area . In addition, common symptoms are fever , nausea, vomiting, a change in bowel behavior from diarrhea to constipation with pus and mucus in the stool and difficulty urinating, called dysuria . The laboratory values show an increase in CRP and leukocytes . In some cases, when examining the abdomen of the person affected, a cylindrical tumor (tumor in the sense of a space-occupying lump) can be felt. The further diagnosis takes place u. a. with the ultrasound and a CT scan of the abdomen. A colonoscopy should also be carried out at intervals in order to rule out other - especially malignant - diseases.
There is no generally binding staging of diverticulitis. A classification proposed by Hansen and Stock is suitable for everyday clinical practice. It represents a pretherapeutic basis for the stage-appropriate therapy of diverticulitis. The findings of the clinical examination, the colonic contrast enema or the colonoscopy and computed tomography of the abdomen are taken into account.
|I.||acute uncomplicated diverticulitis||Pain in the lower abdomen, possibly fever|
|II||acute complicated diverticulitis|
|II a||Peridiverticulitis, phlegmonous diverticulitis||Tension pain, local immune system tension, palpable resistance, fever|
|II b||Abscessing diverticulitis, covered perforation||Local peritonism, fever, intestinal atony|
|II c||free diverticular perforation||Acute abdomen|
|III||chronic recurrent diverticulitis||recurrent lower abdominal pain, constipation, subileus|
According to the AWMF's S2k guideline "Diverticular disease / diverticulitis" from May 2014, the classification of diverticular disease and diverticulitis has been changed, but is still based on the classification by Hansen and Stock.
|Type 0||Asymptomatic diverticulosis||Incidental finding; asymptomatic; No illness|
|Type 1||Acute uncomplicated diverticular disease / diverticulitis|
|Type 1a||Diverticulitis / diverticular disease with no environmental reaction||Symptoms related to diverticula; Signs of inflammation (laboratory); optional: typical sectional imaging|
|Type 1b||Diverticulitis with a phlegmonous surrounding reaction||Signs of inflammation (laboratory); obligatory: sectional imaging: phlegmonous diverticulitis|
|Type 2||Acute complicated diverticulitis like 1b, plus:|
|Type 2a||Micro abscess, covered perforation, small abscess (≤ 1 cm); minimal paracolic air|
|Type 2b||Macro abscess, covered perforation, para or mesocolic abscess (> 1 cm)|
|Type 2c||Free perforation, free air / liquid; generalized peritonitis|
|Type 2c1||Purulent peritonitis|
|Type 2c2||Fecal peritonitis|
|Type 3||Chronic Diverticular Disease; Recurrent or persistent symptomatic diverticular disease|
|Type 3a||Symptomatic uncomplicated diverticular disease (SUDD)||Typical clinic; Signs of inflammation (laboratory): optional|
|Type 3b||Recurrent diverticulitis without complications||Signs of inflammation (laboratory) present; Cross-sectional imaging: typical|
|Type 3c||Recurrent diverticulitis with complications||Detection of stenoses, fistulas, conglomerates|
|Type 4||Diverticular bleeding||Evidence of the source of the bleeding|
- covered perforation , pericolic abscess , Douglas abscess
- free perforation, peritonitis
- Stenosis , possibly ileus
- Bleeding (mostly caecal diverticulum)
- Fistula (e.g. bladder-intestine, possibly with pneumaturia )
- Crohn's disease
- Ulcerative colitis
- Colon cancer , sigmoid cancer
- Irritable bowel syndrome
- ischemic colitis
- Radiation damage to the intestines
- gynecological diseases such as adnexitis , twisted adnexal tumor, extrauterine pregnancy
Treatment is usually carried out in hospital; outpatient antibiotic treatment can only be considered for mild diverticulitis. Possible antibiotics are metronidazole , ciprofloxacin and cefuroxime . Initial zero diet with parenteral nutrition or liquid nutrition can possibly improve the patient's condition by immobilizing the bowel. Applying ice to the affected region of the abdomen (so-called ice bladder) can alleviate the pain of the inflammation and possibly prevent the inflammation from spreading further. Since there is a risk of recurrence with complications (e.g. perforation and then fecal peritonitis ), a resection of the affected section of the intestine in an inflammation-free interval is recommended , especially in the case of recurrent diverticulitis . This general surgical indication from the 2nd attack is now considered obsolete. Nowadays, the indication for surgery is based on the course of the complications, so that several uncomplicated recurrences are not necessarily worth surgery. Nowadays, this elective operation can usually be performed laparoscopically . If complications such as perforation or heavy bleeding occur, an immediate operation is usually necessary. An emergency operation after a serious complication is usually carried out in the form of a so-called Hartmann operation, i.e. H. an enterostoma is temporarily created to avoid suturing two inflamed sections of the intestine - a one-step operation without an enterostoma is, however, also possible here. In the case of a covered perforation, i. H. a perforation that is sealed by neighboring organs, conservative therapy is usually sufficient. Nowadays, an abscess in the inflamed section of the intestine can also be drained percutaneously . The mortality rate for phlegmonous diverticulitis is less than one percent, for abscessing diverticulitis at around 1 to 3 percent and for free perforation at 12 to 24 percent.
- H.-W. Baenkler, D. Fritze among others: Internal medicine . (= Dual row). Georg Thieme Verlag, Stuttgart 2001, ISBN 3-13-128751-9 , pp. 1090-1091.
- H. Barth, A. Böhle et al.: Surgery. (= Dual row). 2nd Edition. Georg Thieme Verlag, Stuttgart 2003, ISBN 3-13-125292-8 , pp. 395-399.
- Diverticulitis images in the endoscopy atlas
- Diverticulitis images in the sonography atlas
- E-learning course on sigmoid diverticulitis with images and videos ( Charité Berlin)
- F. Anne. et al. A High-Fiber Diet Does Not Protect Against Asymptomatic Diverticulosis. In: Gastroenterology. February 2012.
- Hjern, F. et al. : Obesity, physical inactivity, and colonic diverticular disease requiring hospitalization in women: a prospective cohort study . In: Am J Gastroenterol . No. 107 , 2012, p. 296-302 , doi : 10.1038 / ajg.2011.352 , PMID 19062658 .
- M. H. McCafferty, L. Roth, J. Jorden: Current management of diverticulitis . In: The American surgeon . No. 74 (11) , 2008, pp. 1041-1049 , PMID 19062658 .
- Cao, Y. et al. : Meat intake and risk of diverticulitis among men . In: Good . tape 0 , 2017, p. 1–7 , doi : 10.1136 / gutjnl-2016-313082 , PMID 28069830 ( bmj.com [PDF]).
- FL Crowe, PN Appleby, NE Allen, TJ Key: Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians . PMID 21771850 .
- O. Hansen, F. Graupe, W. Stock: Prognosis factors of perforated colon diverticulitis . In: The surgeon . No. 69 (4) , April 1998, pp. 443-449 , doi : 10.1007 / s001040050436 .
- CT Germer, V. Groß: Diverticulitis: When to treat conservatively and when surgically? In: Deutsches Ärzteblatt . No. 104 (50) , 2007, pp. 3486-3491 .
- J. Chapman, M. Davies, B. Wolff, E. Dozois, D. Tessier, J. Harrington, D. Larson: Complicated diverticulitis: is it time to rethink the rules? In: Annals of Surgery . No. 242 (4) , 2005, pp. 576-581 , PMID 16192818 .