acute diverticulitis

(redirected from Weakened bowel wall)

acute diverticulitis

a sudden severe, painful disorder of the intestinal tract, resulting from inflammation of one or more diverticula, or small pouches, in the wall of the bowel. The condition is typically diagnosed through x-rays and treated with antibiotics and/or surgically. If left untreated, the inflamed pouches may rupture, spilling fecal matter into the abdominal cavity and causing peritonitis.

acute diverticulitis

Acute inflammation of a diverticulum of the large (less commonly, small) intestine.
 
Clinical findings
Pain in hypogastrium, which localises to the left lower quadrant; altered bowel habits—diarrhoea > constipation, dysuria, urinary frequency, urgency (if affected segment is close to bladder).
 
Imaging
CT1 is the diagnostic method of choice; it is safe, cost-effective, correlates with diagnosis of acute diverticulitis (AD); false-negative rate: 2% to 21%.

Staging
See Hinchey staging.
 
Management
First attack—liquid diet, 7–10 days of broad-spectrum antibiotics; for refractory AD, “triple therapy” 2 has been advocated; newer broad-spectrum antibiotics (e.g., pipericillin, tazobactam) may be as effective; CT-guided drainage is advocated for peridiverticular abscesses of >5 cm3. Approximately 20% of patients with AD require surgery; in patients who respond to medical management, and in whom diverticular abscesses can be controlled by percutaneous drainage, a single-stage procedure with 1º anastomosis is appropriate, and can be performed by laparoscopy; in emergencies, a 2-stage procedure with resection and colostomy in stage 1, and reanastomosis in stage 2 is preferred.

Acute diverticulitis—pathogenesis
Increased intraluminal pressure (IP), decreased stool bulk, increased GI transit time; hyper-segmentation and increased IP result in herniation of colonic mucosa at weakened areas adjacent to the points of penetration of the vasa recta in the intestinal wall.
 
Weakened bowel wall
Once diverticula develop, undigested food may become entrapped; obstruction of the neck of the diverticulum sets the stage of distension as a result of mucus secretion; diverticula may consist solely of mucosa and are thus susceptible to vascular compromise.

Contrast enemas demonstrate diverticula, but correlate poorly with diagnosis of clinically significant acute diverticulitis, and may dislodge obstructing fecalith, resulting in perforation. Ultrasonography has been advocated for the Dx of AD; findings include hypoechoic thickened colonic segment, the diverticulum per se, hyperechoic pericolonic tissue, and pain on pressure from the transducer.

Cons
Operator-dependent, cannot differentiate between AD and cancer.

Ampicillin, gentamicin, metronidazole
Usually results in defervescence, decreased pain, normalised WBC count.

Generalised peritonitis, uncontrolled sepsis, visceral performation, and acute clinical deterioration.
 
A 3-stage procedure was formerly advocated for AD in which rupture into the peritoneum or obstruction was present; in stage 1, drainage was established and a colostomy placed; in stage 2, the diseased intestine was resected; in stage 3, bowel continuity was restored; given the higher morbidity associated therewith, a 2-stage procedure is now preferred.

acute diverticulitis

GI disease Acute inflammation of a diverticulum of the large–less commonly, small–intestine Staging See Hinchey staging Clinical Pain in hypogastrium, which localizes to the left lower quadrant; altered bowel habits–diarrhea > constipation, dysuria, urinary frequency, urgency–if affected segment is close to bladder Imaging CT is the diagnostic method of choice; it is safe, cost-effective, correlates with diagnosis of AD; false negative rate–2-21% Management First attack-liquid diet, 7-10 days of broad-spectrum antibiotics; for refractory AD, 'triple therapy' has been advocated, although newer broad-spectrum antibiotics–eg, pipericillin, tazobactam, may be as effective; CT-guided drainage is advocated for peridiverticular abscesses of > 5 cm3; ±20% of Pts with AD require surgery; in Pts who respond to medical management, and in whom diverticular abscesses can be controlled by percutaneous drainage, a single-stage procedure with 1º anastomosis is appropriate, and can be performed by laparoscopy; in emergencies, a 2-stage procedure with resection and colostomy in stage one, and reanastomosis in stage 2 is preferred See Diverticular disease.
Acute diverticulitis–pathogenesis
↑ Intraluminal pressure
(IP ↓ stool bulk → ↑ GI transit time → ↑ IP; hypersegmentation and ↑IP result in herniation of colonic mucosa at weakened areas adjacent to the points of penetration of the vasa recta in the intestinal wall–which explains why diverticula are arranged in role
Weakened bowel wall
Once diverticula develop, undigested food may become entrapped; obstruction of the neck of the diverticulum sets the stage of distension as a result of mucus secretion; diverticula may consist solely of mucosa and thus are susceptible to vascular compromise
.

acute diverticulitis

Diverticulitis in which the symptoms are similar to those of appendicitis but usually located in the left rather than the right lower quadrant of the abdomen: inflammation of the peritoneum, formation of an abscess, and in untreated patients, intestinal gangrene accompanied by perforation.
See also: diverticulitis