Today we will discuss a disease of the gastrointestinal tract - diverticulosis. It is not as popular as the ulcer, but it is problematic enough, and sometimes too dangerous. Our interlocutor is Dr. Asen Petrov, a gastroenterologist who heads the internal department of a capital hospital.
Dr. Petrov, let's start standard. What is diverticulosis - in general and accessible terms?
- Colonic diverticula is a condition of pocket-like herniation of the intestinal wall in those areas of it which are weaker and where blood vessels can penetrate. Most often, the sizes of these formations are between 5 and 10 mm. Diverticulosis disease generally includes three conditions - colonic diverticulosis; diverticulitis, which means inflammation of the diverticula, and the third condition is bleeding from those same diverticula. These three different conditions suggest the division of diverticulosis into a simple form - characteristic of 75 percent of patients who do not have complications - and a complicated form. It occurs in 25 percent of patients and is manifested by the development of abscesses, fistulas, obstruction, peritonitis and sepsis.
What is the incidence of diverticulosis?
- The frequency increases with age, with only 5 percent of all cases occurring by the age of 40, and by the sixth decade this indicator is already 30 percent, to reach 65 percent in people over 80 years of age. The frequency also depends on the gender - cases prevail in men who have reached the age of 50. And at the age of 70, women suffer significantly more often. That is, diverticulosis is more common in the elderly. Between 2 and 5 percent are patients under the age of 40 who have such a diagnosis. It is important to note here that this form of diverticulosis in young people occurs more often in obese men. This is the reason that is considered the main risk factor for the appearance of diverticula in the large intestine. The thesis that diverticulosis in young people is a more virulent condition is still being debated worldwide.
Can the causes of the occurrence and development of diverticulosis be specified?
- The first widely cited cause is a low-fiber diet. It is also the first ever described possible etiological reason for the development of diverticulosis in the late 1960s. Despite the fact that at the beginning this thesis met with resistance, its role in the development of this condition is also confirmed by publications. Vegetarians are much less likely to suffer from this disease. Fiber is believed to be a protective agent against the formation of diverticula and, accordingly, diverticulitis. An increased risk of developing diverticulosis exists anyway with a regular intake of food rich in red meat and high in fat. This risk can be reduced by
high fiber diet
especially if they are of cellulose origin - fruits and vegetables. But patients who smoke and take non-steroidal anti-inflammatory drugs, especially paracetamol, have a higher incidence of complications. Other patients at risk are those who are obese and consume a diet low in fiber. The complicated form of this disease is not more common in patients who consume alcohol and caffeinated beverages. Regarding the localization of diverticulosis, in 95 percent of cases the sigmoid colon is affected, most likely due to the small diameter of the sigmoid.
How does diverticulosis manifest itself in its various forms?
- In 70 percent of patients, it is asymptomatic. In 15-25 percent it leads to an inflammatory process - diverticulitis, and in 5-15 percent it is associated with bleeding from the diverticula. Diverticulitis is a complicated form of this disease that includes a spectrum of inflammatory changes that vary from local inflammation to generalized peritonitis with free perforation. For example, the increased pressure of swollen food particles can damage the diverticulum wall, resulting in inflammation and focal necrosis leading to perforation. The clinical appearance of the perforation depends on its size and how quickly it is limited by the surrounding anatomical structures of the body. Perforations that are well controlled cause abscess formation, while incomplete containment may present with free perforation. Simple diverticulitis occurs in 75 percent of cases, and complications - with the formation of abscesses, fistulas and perforations, occur in 25 percent of patients.
And how to recognize the symptoms?
- The majority of patients have pain in the left lower quadrant of the abdomen, as well as recurrent increased sensitivity to palpation. Other important but nonspecific symptoms are fever and leukocytosis. The diagnosis made exclusively on the basis of clinical signs is inaccurate in 33 percent of cases. From a diagnostic point of view, computed tomography is better than ultrasound. Irigoscopy, irrigography and endoscopy are also used. However, an accurate assessment of the condition is necessary because
in acute conditions, emergency surgery is required
due to the increased risk of perforation.
Dr. Petrov, please briefly and accessible explain how conditions such as abscess, perforation, hemorrhages are manifested and controlled?
- The formation of the abscess depends on the spread of the inflammatory process, and the symptoms are high fever and leukocytosis. I.e. increased level of leukocytes and pain on palpation. In 90 percent of the cases, the so-called small pericolic abscesses are managed with antibiotic and conservative therapy. And the so-called percutaneous drainage of the abscess 100% reverses the process and controls the condition. Fortunately, perforation as a complication of diverticulosis is not common and should be suspected especially in immunocompromised patients. Unfortunately, however, it is associated with an increased risk of mortality - in 35 percent of cases the patient dies. Fistulas form as a complication in 2 percent of patients with diverticulosis. They are more common in men and in patients who have undergone previous operations.
So - we got to the bleeding…
- Excluding hemorrhoidal disease, non-neoplastic perianal diseases and colorectal carcinoma, diverticulosis is the most common cause of lower GI bleeding. It is estimated that 15 percent of patients experience a hemorrhage at least once in their lifetime. Bleeding is usually sudden and profuse, and in 33 percent of patients it is massive, requiring an emergency blood transfusion. The good thing is that it stops spontaneously in 70-80 percent of cases. However, non-steroidal anti-inflammatory drugs have been shown to increase bleeding. This condition can be managed conservatively with hemostatic systems and antibiotics, but if there is no improvement within 2-3 days, surgery is resorted to. Emergency surgery for acute hemorrhage is successful in controlling bleeding in 90 percent of cases as a stand-alone method.