19:37,6,Jan,2011 | (4617/0/0) | Original

scattered colonic diverticula

Colonic diverticulosis, colonic diverticula in the colon wall to form bulging pocket. Can be a single, but more a series of highlights from the cystic lumen outward. Colonic diverticulitis can be divided into two types of Authenticity and acquired. True congenital diverticulum is a full-thickness colon wall is weak, diverticulitis with intestinal layers. Department of mucosal diverticula are acquired through the intestinal wall hernia in the muscle weakness, so it is secondary to increased intraluminal pressure, forcing the intestinal mucosa through a weak area protruding muscles. Diagnosis to determine the correct diagnosis of the disease and determine treatment approach is a very important aspect. Some of the signs and symptoms of diverticulitis patient mild conditions can be successfully treated in outpatient, Yan Mountain and some manifestations of acute life-threatening illness who need emergency surgery recovery and save lives. Therefore the most important assessment is repeated clinical examinations and frequent patient checks. This not only includes a history and physical examination, pulse and body temperature, but also as a continuous examination of blood, the peace lying upright abdominal X-ray. When all the typical symptoms and signs are present, the diagnosis of left colonic diverticulitis is simple. In such cases, no additional tests, treatment should be based on assumptions verdict, unfortunately, often do not clear the majority of cases, the initial clinical examination in the diagnosis and severity of attacks may be are not clear. Cases of acute right side colonic diverticulitis make a correct diagnosis before surgery, only 7%. Study of preoperative diagnosis is usually helpless, only delay proper treatment. Has three examination to determine acute left colonic diverticulitis and indications of whether the clinical diagnosis of inflammatory complications was helpful, and this is endoscopy, double contrast barium enema, and abdominal and pelvic CT scan. Endoscopy in the acute situation should generally be avoided, because inflation can induce or aggravate existing perforation perforation. If you take into account the existence of other straight sigmoid colon lesions, and this will change the treatment of disease, can be used for endoscopy, but should not be inflated. Barium enema can be used to diagnose acute diverticulitis, but barium risk of overflow to the abdominal cavity, which would cause serious vascular collapse and death. Hackford other propositions in the inflammatory process subsided after 7 ~ 10d for barium enema to confirm the diagnosis. If you need to rush to make a diagnosis to guide treatment, water-soluble contrast enema can be used, so even if there is overflow to the abdominal contrast agent will not cause serious reactions. Non-invasive CT scan examination, generally confirm the clinical suspicion of diverticulitis. Strengthened when the rectum scan imaging diverticular abscess or fistula can fi
nd X-ray contrast than simply more sensitive. Labs et al reported that CT scanning in the diagnosis of the complications of diverticulitis is more effective: CT scan diagnosis of 10 cases of abscess in 10 cases and 12 cases of fistula in 11 cases, while the X-ray contrast diagnosed eight cases of abscess in two cases and 8 cases of fistula in 3 cases. Another advantage is that CT scans can be guided percutaneous drainage of abscess. Bladder diverticula colonic fistula through the CT scan is best to confirm the diagnosis, about 90% of patients can be diagnosed, cystoscopy may be required, and the fistula site showed focal inflammatory process, barium enema and sigmoidoscopy is not fiber very effective, only about 30% to 40% of the test results were positive. KUB may show lesions secondary to sigmoid colon obstruction. Water-soluble contrast medium enema can confirm the diagnosis. Treatment (a) medical treatment of complications of acute diverticulitis may be used without medical treatment, including fasting, gastrointestinal decompression, intravenous fluids, broad-spectrum antibiotics and close clinical observation. General, gastrointestinal decompression, there is only evidence of vomiting or when the use of bowel obstruction. Control for selection of aerobic and anaerobic gram-negative bacilli many antibiotics, no antibiotics self-limiting acute diverticulitis often seen. Added dietary fiber, and antispasmodic agent in the treatment of acute diverticulitis patient there is no status. After medical treatment, the majority of cases the symptoms will soon ease. (B) of the surgical indications at present that the need for surgical treatment of the case can be divided into two categories, one for uncomplicated diverticular disease: Another cause was complications of diverticular disease, together, with the following conditions on who should be surgical treatment: ① the initial attack of acute diverticulitis had no response to medical therapy; ② recurrent acute diverticulitis, even after the first attack were satisfied with the effect of medical treatment, but relapse should be considered for selective resection; ③ <50 years of age had an attack of acute diverticulitis and with the success of medical treatment cases, elective surgery should be performed emergency surgery to prevent future; ④ immunodeficiency patient as diverticulitis occurs when the inflammatory response can not be aroused enough, so is a fatal disease, the occurrence of perforation, rupture into the free abdominal cavity are very common, for once on the previous episode of acute diverticulitis of the patient when the need for long-term immunosuppressive therapy, before surgery for the selective lifting of recurrence of diverticulitis that the risk of complications occurred; ⑤ acute diverticulitis complicated by abscess or cellulitis; ⑥ acute diverticulitis with diffuse peritonitis were; ⑦ acute diverticulitis complicated by fistula formation; ⑧ acute diverticulitis complicated by bowel obstruction. In the surgical indications, especially in cases without complications do not need to pay particular attention to intestinal bowel syndrome in patients with colonic diverticular disease in patients with diverticulitis mistaken for surgery. According to Morson reported that about 1 / 3 elective surgery for diverticulitis specimens without pathological evidence of inflammation. Therefore, there is no objective signs of inflammation such as fever or white blood cell levels were, intestinal bowel syndrome with colonic diverticular disease should be functional colonic disease management, not as an unnecessary surgery to remove the object. (C) surgery 1. Elective surgery cases, a comprehensive preoperative examination and adequate preparation, including cleaning and antibiotics, bowel preparation. As part of the sigmoid colon is the most common invasion, it is first needed to be sigmoid bowel resection, the resection is controversial, we must determine the appropriate cut nearly cut-side and far side of the colon should be fully free, and to ensure consistent stock Duan good blood supply and tension-free anastomosis. Benn, etc. that will be in the rectal anastomosis can reduce the recurrence of diverticulitis. Not all are subject to removal of colonic diverticula, but the distal anastomosis should not be left in the diverticulum. Suffered from diverticulitis, inflammation of the colon due to previous, the colon serosa always have to change, there is infiltration mesocolon to help identification. But even after the removal of satisfaction, many of the patient will increase the pre-existing diverticulum, diverticular disease will develop, about 7% to 15% will relapse of acute diverticulitis. In the medical treatment of the patient and the patient for surgery, the recurrence of symptoms after a certain time the ratio is the same. Because no response to medical treatment carried out surgery to remove the patient, may not be suitable for preoperative bowel cleansing preparation. In this case, optional for Hartmann surgery, or intraoperative proximal colonic irrigation used after cleaning an end anastomosis, without colostomy. The trend in recent years, more inclined to choose as an anastomosis. After excision of an abscess or even match, no fecal bypass. 2. For the acute inflammatory diverticular disease complications of surgery, the first should be given IV in the second or third generation cephalosporins and metronidazole. Some patient may need to be given from the veins in the dose of stress steroid hormones. Should be estimated before surgery to the pelvic surgeon anatomical factors, there may be a temporary colostomy or ileostomy, which should be patient before surgery and their families that make thoughtful preparation. In addition, acute inflammation, ureter often be involved in the emergency operation in the probability of significant accidental injury, this should be before the operation routine cystoscopy, ureteral catheter placed for support. Emergency surgery patient should take the bladder lithotomy position, the midline abdominal incision for exploration, exploration to determine diagnosis and to determine abdominal inflammation, understanding the adequacy of bowel preparation, and presence of other lesions. It Colcock reported up to 25% of patients for the preoperative diagnosis of diverticulitis with abscess or fistula was found for the perforation of the cancer. Obviously, if it is cancer, removal of the objectives and scope will change. To this end, Haghes et al (1963) to the inflammatory complications of diverticular disease is divided into four categories: ① the limitations of peritonitis; ② around the limitations of the colon or pelvic abscess; ③ around the colon or pelvic abscess diffuse peritonitis after perforation; ④ Free perforation of the colon secondary to diffuse peritonitis. Later, Hinchey et al (1978) proposed the same categories: ① around the colon or mesenteric abscess; ② encapsulated pelvic abscess; ③ diffuse suppurative peritonitis; ④ diffuse fecal peritonitis, this classification is widely used. Killingback 1983, proposed a more complex and fine classification. Complications of diverticular disease with abscess drainage are preferably both, control peritonitis, inflammation and bowel resection. In recent years a lot of information to prove the conservative surgical drainage and colostomy waste disease and mortality were significantly higher than the rate of surgery. The previous three surgical methods have been Phase I and II surgical replaced. The current data show that a large number of surgery is safe, but one or two specific decisions surgery there are several points to be important factors: ① intestine empty, no fecal matter, expressed satisfaction with bowel preparation, or by surgery lavage to achieve this requirement; ② wall without edema; ③ to be a good fit for the intestines to the blood; ④ abdominal infection, and pollution was limited, and not too serious; ⑤ surgeon general condition of the patient and presence of other special risk factor in understanding. In recent years, is keen on a consistent, mainly due to the implementation suffered peritonitis and intestinal reconstruction of Hartmann continuous operation of the patient's difficulties. The two operations have two options, one Hartmann-type remote slit closed, proximal colostomies, the second re-match. In the result of diffuse suppurative peritonitis or diffuse peritonitis and fecal resection line, the general application of this operative. The other is a match, supporting the proximal colostomy or ileostomy or colon bypass, generally applicable for non-diffuse suppurative peritonitis or diffuse fecal peritonitis surgery, but should not be a result of other factors consistent with those. On the right side colonic diverticulitis surgery is still divided, according to Schmit and other views, such as to rule out cancer, colon resection has enough limitations, such as bowel cancer activity can not be excluded or have questions, should be right hemicolectomy. But Fischer and Farkas that the limitations associated with acute diverticulitis in patients with cellulitis, so long as to get rid of cancer, can not be removed, after antibiotic treatment can be successful. Epidemiology of acquired colonic diverticular disease in Western countries exist in a lot of people, but the true prevalence of the disease is still difficult to determine. Radiological data overestimate prevalence because the checks were the subject of the patient with gastrointestinal symptoms. Conversely, autopsy data underestimate the prevalence because of colon examination after death rest rooms can easily be missed. Of those over 45 years of acquired colonic diverticula occur about 5% to 10%,> 85 years of age increased in the 2 / 3 there is disease. In short, regardless of how the real number, in the autopsy and barium enema X-ray examination of acquired colonic diverticulosis increased with age while the increase. 20 centuries ago on the acquired very few reports of colonic diverticular disease. Although the anatomical description of colonic diverticular disease in the early 18th century, but until the 20th century to recognize the clinical signs and histopathology of the relationship. Lies in the West in the 20th century gained rapid popularity of colonic diverticular disease causes can be attributed to a decrease in consumption of dietary fiber. Painter and Buikitt pointed out that in Africa, not seen for 20 years, 1 case of diverticulitis that diverticular disease in industrialized countries and its complications in the increased prevalence is due to diet Zhongyong flour and refined sugar to replace the rough types of food. Although most of the evidence for this theory is inferential and intuitive; and the importance of the status of dietary fiber evidence is from the first generation born in Hawaii of Japanese epidemiological studies, because their diet has been westernized . The incidence of diverticulitis was born in Japan compared to determine the crystal is increased. Acquired colonic diverticular disease in females, according to Parks (1969) reported male to female ratio is 2:3. The average age when treatment was 61.8 years, more than 92% at 50 years of age. 96% of patients with sigmoid colon involvement; 65.5% of the involvement of patients as the only part of the sigmoid colon. About half of the symptoms of the patient before treatment time
scattered colonic diverticula

(A) of the colonic diverticulosis
1. Asymptomatic diverticulum 80% to 85% of diverticular disease have no symptoms, about 55% of asymptomatic patients with right colon diverticula, even if there are mild symptoms seldom seek medical treatment, the left common iliac fossa abdominal symptoms are intermittent or lower abdomen pain, bloating, irregular bowel movements, mucus, tenesmus, weight loss and loss of appetite, etc., anemia is not common, these symptoms may exist simultaneously caused by intestinal bowel syndrome, the nature of change in bowel habits, blood in the stool , abdominal pain with diarrhea, loss of appetite, weight loss and anemia is the performance of colorectal cancer, and diverticular disease only from the history is not easy to identify, suspected cases should be barium enema and colonoscopy, some patients may be associated with hiatal hernia and gall bladder stones, physical examination is usually no positive findings, the normal digital rectal examination, colonoscopy is clear that e-pure colonic diverticulitis.
(B) of acute diverticulitis
When acute abdominal pain and limitations of different degrees, can be presented tingling, dull pain and cramps, mostly in the left lower quadrant pain location, and occasionally in the suprapubic and right lower abdomen, or the entire lower abdomen, constipation or bowel the patient often frequency , or the same patient both, after the exhaust can make pain relief, inflammation adjacent to the bladder can produce urinary frequency, urgency, according to sites of inflammation and severity of nausea and vomiting can also be associated with, physical examination, there is fever, mild abdominal distension, left lower quadrant tenderness, and left lower abdomen or pelvic mass, occult blood in stool, blood in a small number of stool with the naked eye, but in the presence of a peri-diverticulitis bleeding were rare occurrence, in addition, there is mild to moderate increase in white blood cells.
Acute diverticulitis of the colon diverticulosis of the most common complication, according to Rodkey and Welch reported that Massachusetts General Hospital in colonic diverticular disease 43% of cases of acute diverticulitis and localized infection, acute colonic diverticulitis can occur in any parts, including the rectum, in Western countries, the sigmoid colon is the most common site, while in Japan and China, places the right colon is more common in patients with known diverticular disease, about 10% to 25% of patients At least the onset of an acute diverticulitis, diverticulitis occurs despite a large number of rectal bleeding is rare, but acute diverticulitis, 30% to 40% of patients surgery is the first in Shaanxi Province positive fecal occult blood, about 10% to 25% 48h after treatment, although patients with no improvement or even worse require emergency surgical treatment, about 70% for emergency surgery patient whose initial performance are very critical, there is damage to the immune patient response to medical treatment of poor, Perkins other reported patient with this type of fasting, fluid replacement, antibiotics and other treatment, 100% failure, and surgery had higher rates of disease and mortality of waste, therefore, recommend that most transplant centers have confirmed diverticulitis before the one in the transplant Selective resection of the colon, acute diverticulitis in the "40% of the patient is rare, and its clinical course is also more dangerous, Freishlay @ such reports under the age of 77 reported in their first attack the patient would need surgery when the , and the patient usually presents these serious complications such as free perforation, the right colon diverticula is probably in the development of colonic diverticula as part of a small number of right colon diverticulitis involving an isolated process, or more often a isolated a single true diverticulum in the right patient at noon diverticulitis often resembles acute appendicitis.
(C) of acute diverticulitis complicated by abscess
Acute diverticulitis is the most common complication occurring abscess or cellulitis, can be located in the mesenteric, abdominal, pelvic, retroperitoneal, buttocks or scrotum, often in the abdomen or pelvis when a digital rectal examination and a tender palpable mass in the diverticulum abscess caused by different levels accompanied by signs of sepsis.
(D) of acute diverticulitis complicated by peritonitis
When a localized abscess rupture or perforation into the abdominal cavity after the free diverticula can cause purulent or fecal peritonitis, most of these patient showed different degrees of acute abdomen and septic shock, according to reports, the mortality of purulent peritonitis 6%, while the fecal peritonitis mortality is as high as 35%.
(E) of acute diverticulitis with fistula formation
In all patient with acute diverticulitis, fistula occurs in about 2%, but in the final for the surgery the patient diverticular disease compared with 20% in the existence of the fistula, the fistula may come from adjacent organs and inflammatory lesions of the colon and adjacent mesentery adhesion can exist with or without abscess, with the deterioration of the inflammatory process, diverticulitis abscess own decompression, ulceration to the adhesion of the hollow organs to form the fistula, due to abscess drainage has been effective, the results are often exempt from emergency surgery, about 8% of patients with multiple fistula will occur, more often men than women with multiple fistula, suggesting that the sigmoid colon because of women separated from the uterus into the barrier and other hollow organs, the majority of colonic diverticula occur bladder fistula or colon-vaginal fistula patient who had previous hysterectomy, fistula caused by diverticulitis can be violated in many organs, most colon skin fistula
60 years old left colonic diverticulitis bleeding and perforation rate (93.3% and 20%) we
re significantly higher than the right colon (33.3% and 0%), P60-year-old, 21 cases (67.7%), age [1] diverticulum in the right colon in 14 cases (45.2%), located in the left colon in 17 cases (54.8%).
60 years old left colonic diverticulitis bleeding and perforation rate (93.3% and 20%) were significantly higher than the right colon (33.3% and 0%), P [2]. Colonic diverticula on the predilection sites, the reports vary widely at home and abroad, in the West to left colon more common, reports of domestic multi-display occurs in the right colon [3]. Research suggests that this group, with age led to the vulnerability of the intestinal wall, the incidence of left colonic diverticulitis tended to increase. The number and size of the diverticulum large individual differences, this study showed that the majority of single colonic diverticulitis.
Most colonic diverticula as a subclinical, asymptomatic for life, even when the result of endoscopic examination or imaging studies were found.
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