Clinical forms of complicated diverticulitis
Most cases of diverticulitis reported in the Western Hemisphere were located on the left side of the colon, in contrast to what happens in Japan and China, which is more common on the right side, being mostly due to a single diverticulum, and gives the impression of acute appendicitis.
Immunosuppressed patients have only a few of the classic signs and symptoms of the disease, and not respond well to medical treatment, being more frequent than in the free drilling immunocompetent.
In young patients (<50 years) is relatively rare and diverticular disease is only 2-5% of the total but have a very aggressive course with a high incidence of complications (10-23%), and may require surgical treatment in the first episode.
The most frequent complication of acute diverticulitis is the development of abscess or phlegmon, which can be located in mesentery, abdomen, pelvis, retroperitoneum, and scrotal regions gluten, a tumor may be assessed during the hypersensitive abdominal scan established a gradation in the degree of involvement of colonic diverticular infection: Stage I, diverticulitis with associated abscess; Stage II diverticulitis associated with pelvic or retroperitoneal abscess, stage III, diverticulitis associated with purulent peritonitis, and stage IV , diverticulitis associated with fecal peritonitis. The frequency of abscess varies according to the series at around 28%.
Free perforation associated with diverticulitis with purulent or fecal peritonitis is a true picture of acute abdomen, with all its symptoms, which requires immediate resuscitation and rapid surgical treatment. It is less common than the abscess, at between 14-16%.
Fistulae were present in 2% of all patients with diverticulitis, but are found in 20% of those who undergo surgery because of diverticular disease and colo-vesical fistula, the most common, comprising approximately 65% of fistulas of diverticular origin, voiding symptoms with more pronounced that "per se" can manifest in sigmoid diverticulitis proximity, almost always associated fecaluria, pneumaturia, hematuria and urinary infection. Other fistulas such as colovaginals, with symptoms of vaginal discharge fecaloid or expelling air from vagina or ureterocolics are rare but not exceptional, as it were fistulae collagenosis.
Diverticular disease occurs almost 10% of the obstructions of the colon, complete obstruction is rare, but often partially caused by the swelling, spasms and inflammation of diverticulitis, with thickening of the muscular wall of the colon, by repeated subclinical episodes of diverticulitis, with more predisposed the sigmoid colon by its angle. The frequency of episodes of obstruction ranging from 10-21%.
With regard to bleeding complications, the diverticulitis classically represent the second leading cause of chronic bleeding after colon cancer and the leading cause of acute hemorrhage. The bleeding risk in patients with diverticulitis ranges from 11 to 30%, but must be estimated as the numbers below angiodysplasia associated almost 50% of diverticular disease. After an initial bleeding episode, the risk of further rises of 20-25%, and a third in patients who have bled twice exceeds 50%. The diagnosis of certainty is given only selective arteriography in the acute phase, requiring surgical treatment only severe, persistent or recurrent.
Other uncommon manifestations in association with diverticulitis are arthritis and pyoderma gangrenosum with ineffective medical treatment, responding only to the surgical treatment of diverticulitis.
Orthopedic complications in relation to diverticulitis have been described infrequently (42, 43), demonstrating retroperitoneal perforation caused by pain, swelling, functional impotence and emphysema in the left lower limb.
Complications of diverticulitis is more common among patients with renal polycystic kidney, hemodialysis or peritoneal dialysis and transplant. It is believed that immunosuppression is partly responsible,
There are several publications with the association between the administration of high doses of steroids, as well as nonsteroidal anti-inflammatory, and the development of diverticulitis and its complications, especially perforation assuming the inhibition of epithelial proliferation, which predisposes to bacterial invasion of the mucosa, and also because it may mask or attenuate the symptoms of diverticulitis a "sub", delaying clinical manifestations. Although requiring further confirmation, there is no doubt that this association requires our vigilance.
Examination of Diverticulitis
The Rx for Chest and plain abdominal show abnormalities in 30-50% of patients, and may report the existence of signs of obstruction (dilatation of the colon, small intestine and sometimes in cases of incompetence of the ileocecal valve with absence of rectal gas, or sometimes even with pictures of intraluminal mass). In case of abscess, the presence of image displacement of bowel loops, increased density in the area with mass effect or image in "bread crumbs" for the presence of small bubbles of gas produced by anaerobic bacteria, or by a extraluminal considerable amount of gas located in the lower left quadrant of the abdomen, enclosed by the inflammatory process or, if self-drilling, together with a frank pneumoperitoneum, which is best visualized on the chest or Rx Simple abdomen performed standing or supine with left lateral horizontal Rx. All these signs are nonspecific.
The contrast enema, its safety and usefulness in acute diverticulitis is controversial. The contrast barium enema should be avoided, since it went peritoneal cavity causing severe peritonitis, although some radiologists use it with caution in their reviews. Its replacement by water-soluble contrast barium eliminates the risk, advised of any delay of 6-8 weeks in mild or moderate diverticulitis, although many times, to diagnose whether it is a mild / moderate or severe, there are criteria provides radiological opaque enema, and it is in emergencies where it is most used, especially if they feared a hole-in is easy to perform an unprepared bowel, with reduced pressure, to avoid insufflation of air enema with water-soluble contrast used with caution in peritoneal syndromes of left iliac fossa, where a suspected diverticulitis, is a very accurate diagnosis, not dangerous and economically. The typical findings of diverticulitis and radiographic signs that distinguish diverticulitis of inflammatory bowel disease, colon cancer and ischemic colitis, are cited.
Ultrasound is particularly suited to an acute abdominal syndrome of undetermined origin. The detection of diverticula ranges from 5 to 72%, and other signs like the thickening of the wall more than 4 mm and greater than 5 cm in length, with inflammatory signs diverticula, inflammatory changes in fat pericallosa masses or intramural pericolostomy or intramural fistulae, showed a sensitivity of 85-98% and a specificity of 80-97% with figures of negative predictive value 84% and positive predictive value of 93% in the series. Useful for differential diagnosis with appendicitis and in women for the study of nonspecific pain in the pelvis to rule out gynecological inflammatory processes, the use of ultrasound as a diagnostic transabdominal or transvaginal, can identify and diverticulitis its complications.
The support of nuclear medicine in this disease is low, since the scans with leukocytes marked with Tc99m-Hexamethyl oxime used successfully in the detection of inflammatory bowel disease is not specific for diverticulitis, which may be positive in any abdominal inflammation.
Computerized Axial Tomography (CT) is very interesting to show the effect of pericallosa sigmoid diverticulitis from inflammatory mass of the stadium until the abscess pericallosa.
Tomodensitometric signs of diverticulitis have been well described. The most consistent sign is swelling or inflammation of the fat pericallosa. Diverticula are visible in more than 80% of cases. The colic wall thickening in more than 4 mm is present in 70%, with an abscess pericolonic or distance in about half of cases. In one study, about 423 prospective patients, found a sensitivity of 97% of the TAC for the characterization of the severity of diverticulitis, especially in the formation of abscesses or display contrast or gas Extracolonic . In the same way, the demo is very tomodensitometric for the diagnosis of fistulas, especially sigmoid bladder assessed the association of diverticula, thickening of the wall parallel colic and the bladder wall, and presence of gas in the bladder. In a study, CT was positive for the diagnosis in 8 out of 9 cases, and another was suspected.
The studies conducted until now with the helical CT is not sufficient to determine the benefits that could cause on the conventional CT.
Several studies have evaluated the CT compared with the opaque enema. The sensitivity of the two tests is comparable like its specificity (60-95% according to strict criteria are used or large). By contrast, the rate of false negatives would be higher in the case of CT (20%) than the opaque enema (15%). The limits of tomodensitometric diagnosis of sigmoid diverticulitis are due to the difficulty of the differential diagnosis of sigmoid cancer and a lack of visualization of leakage extraluminal minimal. Most clinicians and radiologists have agreed to use emergency and enema with water-soluble contrast (Gastrografin), because of its availability, ease of implementation and performance diagnosis. CT is indicated in those patients in the enema is impossible or inconclusive, where an abscess is suspected uncertain diagnosis, medical treatment failure or as otherwise provided by a percutaneous puncture drainage directed.
A recent comparative study between sonography and CT evaluation in the diagnosis of diverticulitis show similar results, while another retrospective study adds that although ultrasound is valid by first intention, if the diverticulitis is severe, you should tomodensitometric continued exploration.
The MRI appears to be an effective technique in the evaluation of intestinal ailments, particularly in regard to the diverticulitis. The images offered by the thickening of the colon wall are more conclusive than those of CT.Colonoscopy is generally recommended for urgent because of its difficulty, its practice and especially painful because of the risk of drilling to breathe the air, although you could try rectosigmoidoscopy with a rigid tube without insufflation, or with the pediatric colonoscope.
The emergency colonoscopy contributes little to the diagnosis of sigmoid diverticulitis because the lesions are more prediverticular that mucosal or intraluminal.
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