Chapter 12. NON-TUMOROUS DISEASES OF THE LARGE INTESTINE

Definition and statistical data

Diverticulum is a sacciform protrusion of all layers of the intestinal wall (true or congenital diverticulum) or only of the mucous membrane through the defects in the muscular layer (false or acquired diverticulum).

Diverticulosis means the presence of multiple diverticula.

Diverticular disease means the presence of a diverticulum or diverticulosis accompanied by clinical manifestations.

Diverticula are most frequently localized in the descending colon and sigmoid colon (70-85%), more rarely - in the transverse colon and caecum. The sizes of diverticula may vary from several millimeters to several centimeters. In diverticulosis their number varies from several diverticula to tens and hundreds.

They are detected equally often in males and females. Mainly the population of industrially well-developed countries (with a high life level and longer life span) is affected.

The morbidity incidence grows with age. People under 40 years suffer from diverticulosis of the large intestine in 10% of cases. Diverticula occur in more than 50% of the population above 70 years.

Clinical picture

Diverticula of the large intestine have an asymptomatic course in 70% of cases. They are revealed accidentally during endoscopic or roentgenological investigations. Clinical signs appear when complications develop: diverticulitis, hemorrhage, perforation, intestinal obstruction, fistulas.

Diverticulitis

Complaints

Pain at the place of the diverticulum localization, most commonly - in the left iliac region. Nausea, vomiting, abdominal distention, unstable stools, admixture of mucus in the feces, weakness are possible.

Anamnesis

A long-time course (for several weeks). Periodicity of exacerbations. An acute onset with a violent pain and hyperthermia is possible.

Physical examination

Local tenderness. Abdominal wall muscles tension, detection of an infiltrate by palpation are possible.

Laboratory findings

Subfebrility, leukocytosis, elevated ESR are possible.

Instrumental studies

Irrigoscopy. It allows revealing the presence, localization and number of diverticula, signs of inflammation: segmental peristalsis, intensification, haustra asymmetricity, swelling and disarrangement of the mucous membrane folds. Endoscopy (rectoromanoscopy, colonoscopy). It allows revealing the inflamed mucosa of the diverticula ostium.

CT. It allows assessing the signs of the diverticula inflammation.

Treatment of diverticula of the large intestine

Form of the disease

Methods of treatment

Means of treatment

Accidentally revealed asymptomatic diverticula

Diet with increased amount of cellulose

Wheat bran reducing the intracavital pressure and accelerating the movement of intestinal contents. Limitation of food products contributing to the development of meteorism (peas, kidney beans, grapes, etc.)

Diverticula with moderate clinical manifestations (without pronounced local and general signs of inflammation)

Diet, out-patient medicamentous treatment

Spasmolytics, prokinetics, vitamins A, E, folic acid

Diverticulitis with pronounced clinical picture (signs of general and local inflammation), the first 1-3 episodes

Diet. Medicamentous treatment in conditions of a coloproctological department of the hospital

Antibacterial agents of a wide action spectrum, spasmolytical analgetic agents, alimentary enzymes, intestinal microflora restoration agents, purgative agents

Recurring diverticulitis (more than 3 episodes of pronounced clinical manifestations)

Planned surgical intervention

Resection of the damaged intestinal section with application of interintestinal anastomosis

Occurred hemorrhage of minor intensity from the diverticulum (a small amount of blood in the feces, circulating blood deficiency of less

than 500 ml)

Medicamentous treatment in conditions of a coloproctological department of the hospital

Medicamentous treatment of diverticulitis, hemostatic therapy

Stable recurring hemorrhages

Planned surgical intervention

Resection of the damaged intestinal section with application of interintestinal anastomosis

Occurred hemorrhage with the bloodloss of more than 500 ml and continuous hemorrhage

Emergent surgical intervention

Resection of the damaged intestinal section, more frequently - with application of interintestinal anastomosis

Perforation of the diverticulum into the abdominal cavity, generalized peritonitis

Emergent surgical intervention

Resection of the damaged intestinal section (more frequently - obstructive), sanation and drainage of the abdominal cavity. In neglected peritonitis and critical patient's condition - removal of the perforated intestinal section onto the abdominal wall is performed.

Acute intestinal obstruction

Emergent surgical intervention

Resection of the damaged intestinal section (more frequently - obstructive)

Internal and external fistulas

Planned surgical intervention

Disintegration of fistulas, resection of the damaged intestinal section, more frequently - with application of interintestinal anastomosis

Definition and statistical data

It is a chronic recurring non-specific disease characterized by transmural granulomatous inflammation with segmental damage of various portions of the gastrointestinal tract.

The incidence of morbidity with Crohn's disease constitutes 4-6, and its spread is about 30-50 persons per 100000 of the population. Males and females are affected equally often.The highest morbidity incidence is noted in people of 15-35 and above 60 years. Crohn's disease most frequently occurs in the Northern Europe and Northern America. Morbidity incidence in Russia constitutes 3.5 per 100000 people. Crohn's disease may affect any section of the alimentary tube. The large intestine is damaged in 30% of patients. The esophagus, stomach and duodenum are damaged in 3-5% of patients,small intestine - in 25-30% of patients. Combined affection of the small and large intestines is noted in 40-45% of patients.

Evaluation of the disease severity

Severity of the disease is evaluated by calculation of Crohn' s disease activity index (CDAI) according to Best. During 7 days there are evaluated: frequency of defecation acts, markedness of abdominal pain, general physical state, presence of fever, body mass deficiency, presence of extraintestinal manifestations. Presence of fistulas, anal fissure, infiltrates in the abdominal cavity, hematocrit level, intake of anti-diarrheal agents are also taken into consideration.

Index

Value

Coefficient

Watery or gruel-like stool

number of defecations for the last 7 days

2

Abdominal pain

lacking - 0;

slight - 1;

moderate - 2;

intensive - 3

5

General physical state for the last 7 days

good - 0;

satisfactory - 1;

unsatisfactory - 2;

bad - 3;

very bad - 4

7

Other manifestations (complications)

arthritis or arthralgia - 1;

lesions of the skin or mouth - 1;

iritis or uveitis - 1;

anal fissures, fistulas - 1;

perianal abscesses - 1;

external fistulas - 1;

fever - 1.

20

Use of consolidating agents

no - 0;

yes - 1

30

Inflammatory infiltrate

lacking - 0;

doubtful - 2;

detectable - 5

10

Hematocrit

the index is less than:

47% in males;

42% in females

6

Body weight

100 x [1-(weight of the patient/average body mass)]

1

The value of each index is multiplied to the corresponding coefficient, the obtained figures are summed up. The value of the obtained index less than 150 corresponds to remission, the index of 150-220 corresponds to the mild course of the disease, the index of 221-450 indicates the course of average severity, the index of more than 450 points corresponds to a high inflammation activity and a severe course.