Pub Date : 2015-06-01Epub Date: 2015-06-11DOI: 10.1159/000433589
Daniele Marrelli, Costantino Voglino, Giulio Di Mare, Francesco Ferrara, Gianni Guazzi, Federica Croce, Maurizio Costantini, Riccardo Piagnerelli, Franco Roviello
Background: Intestinal stenosis of Garré, first described in 1892, is a rare condition as a consequence of a complicated strangulated hernia. Preoperative diagnosis is challenging because of unspecific symptoms. Proper anamnesis, especially in terms of clinical and surgical history, as well as careful examination of both inguinal spaces is essential.
Case report: We herein present a case of intestinal stenosis of Garré in a 70-year-old female.
Conclusion: Intestinal stenosis of Garré should be considered in cases of occlusive symptoms occurring after a non-operative or surgical reduction of a strangulated hernia. A correct diagnosis and an adequate surgical treatment are necessary to solve this rare complication favorably.
{"title":"Intestinal Stenosis of Garré: An Old Problem Revisited.","authors":"Daniele Marrelli, Costantino Voglino, Giulio Di Mare, Francesco Ferrara, Gianni Guazzi, Federica Croce, Maurizio Costantini, Riccardo Piagnerelli, Franco Roviello","doi":"10.1159/000433589","DOIUrl":"https://doi.org/10.1159/000433589","url":null,"abstract":"<p><strong>Background: </strong>Intestinal stenosis of Garré, first described in 1892, is a rare condition as a consequence of a complicated strangulated hernia. Preoperative diagnosis is challenging because of unspecific symptoms. Proper anamnesis, especially in terms of clinical and surgical history, as well as careful examination of both inguinal spaces is essential.</p><p><strong>Case report: </strong>We herein present a case of intestinal stenosis of Garré in a 70-year-old female.</p><p><strong>Conclusion: </strong>Intestinal stenosis of Garré should be considered in cases of occlusive symptoms occurring after a non-operative or surgical reduction of a strangulated hernia. A correct diagnosis and an adequate surgical treatment are necessary to solve this rare complication favorably.</p>","PeriodicalId":49114,"journal":{"name":"Viszeralmedizin","volume":"31 3","pages":"209-11"},"PeriodicalIF":0.0,"publicationDate":"2015-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000433589","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34089744","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: The clinical spectrum of sigmoid diverticulitis (SD) varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications. Sigmoid colectomy with restoration of continuity has been the prevailing modality for treating acute and recurrent SD, and is often performed as a laparoscopy-assisted procedure. For elective sigmoid colectomy, the postoperative morbidity rate is 15-20% whereas morbidity rates reach up to 30% in patients who undergo emergency surgery for perforated SD. Some of the more common and serious surgical complications after sigmoid colectomy are anastomotic leaks and peritonitis, wound infections, small bowel obstruction, postoperative bleeding, and injuries to the urinary tract structures. Regarding the management of complications, it makes no difference whether the complication is a result of an emergency or an elective procedure. Methods: The present work gives an overview of the management of complications in the surgical treatment of SD based on the current literature. Results: To achieve successful management, early diagnosis is mandatory in cases of deviation from the normal postoperative course. If diagnostic procedures fail to deliver a correlate for the clinical situation of the patient, re-laparotomy or re-laparoscopy still remain among the most important diagnostic and/or therapeutic principles in visceral surgery when a patient's clinical status deteriorates. Conclusion: The ability to recognize and successfully manage complications is a crucial part of the surgical treatment of diverticular disease and should be mastered by any surgeon qualified in this field.
{"title":"Management of Complications Following Emergency and Elective Surgery for Diverticulitis","authors":"C. Holmer, M. Kreis","doi":"10.1159/000377696","DOIUrl":"https://doi.org/10.1159/000377696","url":null,"abstract":"Background: The clinical spectrum of sigmoid diverticulitis (SD) varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications. Sigmoid colectomy with restoration of continuity has been the prevailing modality for treating acute and recurrent SD, and is often performed as a laparoscopy-assisted procedure. For elective sigmoid colectomy, the postoperative morbidity rate is 15-20% whereas morbidity rates reach up to 30% in patients who undergo emergency surgery for perforated SD. Some of the more common and serious surgical complications after sigmoid colectomy are anastomotic leaks and peritonitis, wound infections, small bowel obstruction, postoperative bleeding, and injuries to the urinary tract structures. Regarding the management of complications, it makes no difference whether the complication is a result of an emergency or an elective procedure. Methods: The present work gives an overview of the management of complications in the surgical treatment of SD based on the current literature. Results: To achieve successful management, early diagnosis is mandatory in cases of deviation from the normal postoperative course. If diagnostic procedures fail to deliver a correlate for the clinical situation of the patient, re-laparotomy or re-laparoscopy still remain among the most important diagnostic and/or therapeutic principles in visceral surgery when a patient's clinical status deteriorates. Conclusion: The ability to recognize and successfully manage complications is a crucial part of the surgical treatment of diverticular disease and should be mastered by any surgeon qualified in this field.","PeriodicalId":49114,"journal":{"name":"Viszeralmedizin","volume":"31 1","pages":"118 - 123"},"PeriodicalIF":0.0,"publicationDate":"2015-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000377696","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64774850","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Diverticulosis is a very common condition. Around 20% of diverticula carriers are believed to suffer from diverticular disease during their lifetime. This makes diverticular disease one of the clinically and economically most significant conditions in gastroenterology. The etiopathogenesis of diverticulosis and diverticular disease is not well understood. Epidemiological studies allowed to define risk factors for the development of diverticulosis and the different disease entities associated with it, in particular diverticulitis, perforation, and diverticular bleeding. Methods: A comprehensive literature search was performed, and the current knowledge about risk factors for diverticulosis and associated conditions reviewed. Results: Non-controllable risk factors like age, sex, and genetics, and controllable risk factors like foods, drinks, and physical activity were identified, as well as comorbidities and drugs which increase or decrease the risk of developing diverticula or of suffering from complications. In naming risk factors, it is of utmost importance to differentiate between diverticulosis and the different disease entities. Conclusion: Risk factors for diverticulosis and diverticular disease may give a clue towards the possible etiopathogenesis of the conditions. More importantly, knowledge of comorbidities and particularly drugs conferring a risk for development of complicated disease is crucial for patient management.
{"title":"Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking","authors":"S. Böhm","doi":"10.1159/000381867","DOIUrl":"https://doi.org/10.1159/000381867","url":null,"abstract":"Background: Diverticulosis is a very common condition. Around 20% of diverticula carriers are believed to suffer from diverticular disease during their lifetime. This makes diverticular disease one of the clinically and economically most significant conditions in gastroenterology. The etiopathogenesis of diverticulosis and diverticular disease is not well understood. Epidemiological studies allowed to define risk factors for the development of diverticulosis and the different disease entities associated with it, in particular diverticulitis, perforation, and diverticular bleeding. Methods: A comprehensive literature search was performed, and the current knowledge about risk factors for diverticulosis and associated conditions reviewed. Results: Non-controllable risk factors like age, sex, and genetics, and controllable risk factors like foods, drinks, and physical activity were identified, as well as comorbidities and drugs which increase or decrease the risk of developing diverticula or of suffering from complications. In naming risk factors, it is of utmost importance to differentiate between diverticulosis and the different disease entities. Conclusion: Risk factors for diverticulosis and diverticular disease may give a clue towards the possible etiopathogenesis of the conditions. More importantly, knowledge of comorbidities and particularly drugs conferring a risk for development of complicated disease is crucial for patient management.","PeriodicalId":49114,"journal":{"name":"Viszeralmedizin","volume":"31 1","pages":"84 - 94"},"PeriodicalIF":0.0,"publicationDate":"2015-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000381867","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64786150","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Diverticulitis is one of the leading indications for elective colonic resections although there is an ongoing controversial discussion about classification, stage-dependent therapeutic options, and therapy settings. As there is a rising trend towards conservative therapy for diverticular disease even in patients with a complicated form of diverticulitis, we provide a compact overview of current surgical therapy principles and the remaining questions to be answered.
{"title":"Elective Surgery for Sigmoid Diverticulitis - Indications, Techniques, and Results","authors":"C. Jurowich, C. Germer","doi":"10.1159/000381500","DOIUrl":"https://doi.org/10.1159/000381500","url":null,"abstract":"Diverticulitis is one of the leading indications for elective colonic resections although there is an ongoing controversial discussion about classification, stage-dependent therapeutic options, and therapy settings. As there is a rising trend towards conservative therapy for diverticular disease even in patients with a complicated form of diverticulitis, we provide a compact overview of current surgical therapy principles and the remaining questions to be answered.","PeriodicalId":49114,"journal":{"name":"Viszeralmedizin","volume":"31 1","pages":"112 - 116"},"PeriodicalIF":0.0,"publicationDate":"2015-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000381500","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64782105","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
S. Kuru, K. Kısmet, A. M. Barlas, S. Tuncal, P. Celepli, H. Surer, E. Ogus, E. Ertaş
Background: Montelukast is a cysteinyl-leukotriene type 1 (CysLT1) selective receptor antagonist. In recent years, investigations have shown that montelukast possesses secondary anti-inflammatory activities and also antioxidant effects. For this reason, we aimed to determine the possible effects of montelukast on liver damage in experimental obstructive jaundice. Methods: 30 Wistar-Albino male rats were randomized and divided into three groups of 10 animals each: group I, sham-operated; group II, ligation and division of the common bile duct (BDL) followed by daily intraperitoneal injection of 1 ml of saline; group III, BDL followed by daily intraperitoneal injection of 10 mg/kg montelukast dissolved in saline. The animals were killed on postoperative day 7 by high-dose diethyl ether inhalation. Blood and liver samples were taken for examination. Results: In this study, liver malondialdehyde (MDA) (p = 0.001), myeloperoxidase (p = 0.003), and total sulfhydryl (SH) (p = 0.009) were found to be significantly different between the BDL + montelukast and the BDL groups. Plasma total SH (p = 0.002) and MDA (p = 0.027) values were also statistically different between these groups. Statistical analyses of histological activity index scores showed that the histopathological damage in the BDL + montelukast group was significantly less than the damage in the control group (p < 0.05 for all pathological parameters). Conclusion: According to the results of this study, montelukast showed a significant hepatoprotective effect in this experimental obstructive jaundice model, which might be due to its antioxidant and anti-inflammatory activities.
{"title":"The Effect of Montelukast on Liver Damage in an Experimental Obstructive Jaundice Model","authors":"S. Kuru, K. Kısmet, A. M. Barlas, S. Tuncal, P. Celepli, H. Surer, E. Ogus, E. Ertaş","doi":"10.1159/000375434","DOIUrl":"https://doi.org/10.1159/000375434","url":null,"abstract":"Background: Montelukast is a cysteinyl-leukotriene type 1 (CysLT1) selective receptor antagonist. In recent years, investigations have shown that montelukast possesses secondary anti-inflammatory activities and also antioxidant effects. For this reason, we aimed to determine the possible effects of montelukast on liver damage in experimental obstructive jaundice. Methods: 30 Wistar-Albino male rats were randomized and divided into three groups of 10 animals each: group I, sham-operated; group II, ligation and division of the common bile duct (BDL) followed by daily intraperitoneal injection of 1 ml of saline; group III, BDL followed by daily intraperitoneal injection of 10 mg/kg montelukast dissolved in saline. The animals were killed on postoperative day 7 by high-dose diethyl ether inhalation. Blood and liver samples were taken for examination. Results: In this study, liver malondialdehyde (MDA) (p = 0.001), myeloperoxidase (p = 0.003), and total sulfhydryl (SH) (p = 0.009) were found to be significantly different between the BDL + montelukast and the BDL groups. Plasma total SH (p = 0.002) and MDA (p = 0.027) values were also statistically different between these groups. Statistical analyses of histological activity index scores showed that the histopathological damage in the BDL + montelukast group was significantly less than the damage in the control group (p < 0.05 for all pathological parameters). Conclusion: According to the results of this study, montelukast showed a significant hepatoprotective effect in this experimental obstructive jaundice model, which might be due to its antioxidant and anti-inflammatory activities.","PeriodicalId":49114,"journal":{"name":"Viszeralmedizin","volume":"31 1","pages":"131 - 138"},"PeriodicalIF":0.0,"publicationDate":"2015-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000375434","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64771754","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Diverticular disease is a common problem. Prevention and treatment of complications depend on the stage of the disease. Lifestyle modifications are suitable preventive measures, aiming to reduce obesity and to balance the diet with a high amount of fiber and a low amount of meat. However, evidence to guide the pharmacological treatment of diverticular disease and diverticulitis is limited. Methods: Literature review. Results: Antibiotics are not proven to be effective in patients with uncomplicated diverticulitis and without further risk factors; neither do they improve treatment nor prevent complications. Mesalazine might have an effect on pain relief in diverticular disease even though it has no significant effect on the outcome of diverticulitis. In complicated diverticulitis, inpatient treatment including antibiotics is mandatory. Conclusion: Evidence for the treatment of diverticular disease is limited. Further research is needed.
{"title":"Prevention and Conservative Therapy of Diverticular Disease","authors":"E. Kruse, L. Leifeld","doi":"10.1159/000377651","DOIUrl":"https://doi.org/10.1159/000377651","url":null,"abstract":"Background: Diverticular disease is a common problem. Prevention and treatment of complications depend on the stage of the disease. Lifestyle modifications are suitable preventive measures, aiming to reduce obesity and to balance the diet with a high amount of fiber and a low amount of meat. However, evidence to guide the pharmacological treatment of diverticular disease and diverticulitis is limited. Methods: Literature review. Results: Antibiotics are not proven to be effective in patients with uncomplicated diverticulitis and without further risk factors; neither do they improve treatment nor prevent complications. Mesalazine might have an effect on pain relief in diverticular disease even though it has no significant effect on the outcome of diverticulitis. In complicated diverticulitis, inpatient treatment including antibiotics is mandatory. Conclusion: Evidence for the treatment of diverticular disease is limited. Further research is needed.","PeriodicalId":49114,"journal":{"name":"Viszeralmedizin","volume":"31 1","pages":"103 - 106"},"PeriodicalIF":0.0,"publicationDate":"2015-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000377651","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64773627","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
computed tomography) as cross-sectional imaging procedure, and classification. The new classification, owed to the S2k guideline ‘Diverticular Disease/Diverticulitis’ of the Deutsche Gesellschaft für Gastroenterologie, Verdauungsund Stoffwechselkrankheiten (DGVS) and the Deutsche Gesellschaft für Allgemeinund Viszeralchirurgie (DGAV) from 2014, comprises the entire spectrum of diverticular disease, and is well applicable in ambulant patients as well as in the emergency setting. Along with this guideline, ultrasonography has been fostered as the method of choice in the initial diagnosis and follow-up of diverticulitis while colonoscopy is not required for diverticulitis but for differential diagnoses with atypical course, e.g. segmental colitis associated with diverticulosis (SCAD), symptomatic uncomplicated diverticular disease (SUDD), or mesenteric inflammatory veno-occlusive disease (MIVOD). Computed tomography, however, has still a role in critical situations and cases of inadequate ultrasound performance or insufficient ultrasound imaging quality. The core indication for colonoscopy along with interventional therapy, however, is diverticular bleeding. When and under which circumstances colonoscopy can be safely performed in cases of suspected diverticulitis, is a matter of debate and the topic of a round table discussion among experienced clinical endoscopists and practitioners. While recommendations for primary or secondary prevention reasonably reflect epidemiological findings but lack interventional proof throughout, conservative therapy relies on antibiotic therapy in complicated diverticulitis (type 2); however, in uncomplicated diverticulitis (type 1) antibiotic therapy has recently been questioned in the literature. Whether the time has already come to change daily practice, as well as the value of supportive measures is addressed in another review. The surgical strategy for the optimal treatment of acute complicated diverticulitis has been a matter of debate, and has undergone significant changes in recent years. Owing to interventional technological progress and laparoscopic treatment modalities, the main focus of surgical therapy is on controlling emergency situations and avoiding Hartmann’s procedures. Diverticulosis, diverticular disease, and diverticulitis describe an increasingly important colonic abnormality and its complications. While colonic diverticulosis is not a disease per se, lifestyle or drugs may be determining factors for complications. Medical awareness, however, has been focused during the past decades on conservative therapy relying on antibiotics on the one hand and surgical treatment either in the elective or emergency setting on the other hand. After the introduction of laparoscopic surgery, sigmoid colon resection became a very frequently performed procedure, which accordingly has led to technical perfection but also to the need to define the role of surgery in the contemporary setting. Therefore, now is the t
{"title":"Diverticulitis","authors":"B. Lembcke, F. Köckerling","doi":"10.1159/000381887","DOIUrl":"https://doi.org/10.1159/000381887","url":null,"abstract":"computed tomography) as cross-sectional imaging procedure, and classification. The new classification, owed to the S2k guideline ‘Diverticular Disease/Diverticulitis’ of the Deutsche Gesellschaft für Gastroenterologie, Verdauungsund Stoffwechselkrankheiten (DGVS) and the Deutsche Gesellschaft für Allgemeinund Viszeralchirurgie (DGAV) from 2014, comprises the entire spectrum of diverticular disease, and is well applicable in ambulant patients as well as in the emergency setting. Along with this guideline, ultrasonography has been fostered as the method of choice in the initial diagnosis and follow-up of diverticulitis while colonoscopy is not required for diverticulitis but for differential diagnoses with atypical course, e.g. segmental colitis associated with diverticulosis (SCAD), symptomatic uncomplicated diverticular disease (SUDD), or mesenteric inflammatory veno-occlusive disease (MIVOD). Computed tomography, however, has still a role in critical situations and cases of inadequate ultrasound performance or insufficient ultrasound imaging quality. The core indication for colonoscopy along with interventional therapy, however, is diverticular bleeding. When and under which circumstances colonoscopy can be safely performed in cases of suspected diverticulitis, is a matter of debate and the topic of a round table discussion among experienced clinical endoscopists and practitioners. While recommendations for primary or secondary prevention reasonably reflect epidemiological findings but lack interventional proof throughout, conservative therapy relies on antibiotic therapy in complicated diverticulitis (type 2); however, in uncomplicated diverticulitis (type 1) antibiotic therapy has recently been questioned in the literature. Whether the time has already come to change daily practice, as well as the value of supportive measures is addressed in another review. The surgical strategy for the optimal treatment of acute complicated diverticulitis has been a matter of debate, and has undergone significant changes in recent years. Owing to interventional technological progress and laparoscopic treatment modalities, the main focus of surgical therapy is on controlling emergency situations and avoiding Hartmann’s procedures. Diverticulosis, diverticular disease, and diverticulitis describe an increasingly important colonic abnormality and its complications. While colonic diverticulosis is not a disease per se, lifestyle or drugs may be determining factors for complications. Medical awareness, however, has been focused during the past decades on conservative therapy relying on antibiotics on the one hand and surgical treatment either in the elective or emergency setting on the other hand. After the introduction of laparoscopic surgery, sigmoid colon resection became a very frequently performed procedure, which accordingly has led to technical perfection but also to the need to define the role of surgery in the contemporary setting. Therefore, now is the t","PeriodicalId":49114,"journal":{"name":"Viszeralmedizin","volume":"31 1","pages":"74 - 75"},"PeriodicalIF":0.0,"publicationDate":"2015-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000381887","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64786337","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
T. Wedel, M. Barrenschee, C. Lange, F. Cossais, M. Böttner
Diverticula of the colon are pseudodiverticula defined by multiple outpouchings of the mucosal and submucosal layers penetrating through weak spots of the muscle coat along intramural blood vessels. A complete prolapse consists of a diverticular opening, a narrowed neck, and a thinned diverticular dome underneath the serosal covering. The susceptibility of diverticula to inflammation is explained by local ischemia, translocation of pathogens due to retained stool, stercoral trauma by fecaliths, and microperforations. Local inflammation may lead to phlegmonous diverticulitis, paracolic/mesocolic abscess, bowel perforation, peritonitis, fistula formation, and stenotic strictures. Diverticular bleeding is due to an asymmetric rupture of distended vasa recta at the diverticular dome and not primarily linked to inflammation. Structural and functional changes of the bowel wall in diverticular disease comprise: i) Altered amount, composition, and metabolism of connective tissue; ii) Enteric myopathy with muscular thickening, deranged architecture, and altered myofilament composition; iii) Enteric neuropathy with hypoganglionosis, neurotransmitter imbalance, deficiency of neurotrophic factors and nerve fiber remodeling; and iv) Disturbed intestinal motility both in vivo (increased intraluminal pressure, motility index, high-amplitude propagated contractions) and in vitro (altered spontaneous and pharmacologically triggered contractility). Besides established etiologic factors, recent studies suggest that novel pathophysiologic concepts should be considered in the pathogenesis of diverticular disease.
{"title":"Morphologic Basis for Developing Diverticular Disease, Diverticulitis, and Diverticular Bleeding","authors":"T. Wedel, M. Barrenschee, C. Lange, F. Cossais, M. Böttner","doi":"10.1159/000381431","DOIUrl":"https://doi.org/10.1159/000381431","url":null,"abstract":"Diverticula of the colon are pseudodiverticula defined by multiple outpouchings of the mucosal and submucosal layers penetrating through weak spots of the muscle coat along intramural blood vessels. A complete prolapse consists of a diverticular opening, a narrowed neck, and a thinned diverticular dome underneath the serosal covering. The susceptibility of diverticula to inflammation is explained by local ischemia, translocation of pathogens due to retained stool, stercoral trauma by fecaliths, and microperforations. Local inflammation may lead to phlegmonous diverticulitis, paracolic/mesocolic abscess, bowel perforation, peritonitis, fistula formation, and stenotic strictures. Diverticular bleeding is due to an asymmetric rupture of distended vasa recta at the diverticular dome and not primarily linked to inflammation. Structural and functional changes of the bowel wall in diverticular disease comprise: i) Altered amount, composition, and metabolism of connective tissue; ii) Enteric myopathy with muscular thickening, deranged architecture, and altered myofilament composition; iii) Enteric neuropathy with hypoganglionosis, neurotransmitter imbalance, deficiency of neurotrophic factors and nerve fiber remodeling; and iv) Disturbed intestinal motility both in vivo (increased intraluminal pressure, motility index, high-amplitude propagated contractions) and in vitro (altered spontaneous and pharmacologically triggered contractility). Besides established etiologic factors, recent studies suggest that novel pathophysiologic concepts should be considered in the pathogenesis of diverticular disease.","PeriodicalId":49114,"journal":{"name":"Viszeralmedizin","volume":"31 1","pages":"76 - 82"},"PeriodicalIF":0.0,"publicationDate":"2015-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000381431","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64781079","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: While detailed history, physical examination, and laboratory tests are of great importance when examining a patient with diverticular disease, they are not sufficient to diagnose (or stratify) diverticulitis without cross-sectional imaging (ultrasonography (US), computed tomography (CT)). Methods: Qualified US has diagnostic value equipotent to qualified CT, follows relevant legislation for radiation exposure protection, and is frequently effectual for diagnosis. Furthermore, its unsurpassed resolution allows detailed investigation down to the histological level. Subsequently, US is considered the first choice of imaging in diverticular disease. Vice versa, CT has definite indications in unclear/discrepant situations or insufficient US performance. Results: Endoscopy is not required for the diagnosis of diverticulitis and shall not be performed in the acute attack. Colonoscopy, however, is warranted after healing of acute diverticulitis, prior to elective surgery, and in atypical cases suggesting other diagnoses. Perforation/abscess must be excluded before colonoscopy. Conclusion: Reliable diagnosis is fundamental for surgical, interventional, and conservative treatment of the different presentations of diverticular disease. Not only complications of acute diverticulitis but also a number of differential diagnoses must be considered. For an adequate surgical strategy, correct stratification of complications is mandatory. Subsequently, in the light of currently validated diagnostic techniques, the consensus conference of the German Societies of Gastroenterology (DGVS) and of Visceral Surgery (DGAV) has passed a new classification of diverticulitis displaying the different facets of diverticular disease. This classification addresses different types (not stages) of the condition, and includes symptomatic diverticular disease (SUDD), largely resembling irritable bowel syndrome, as well as diverticular bleeding.
{"title":"Diagnosis, Differential Diagnoses, and Classification of Diverticular Disease","authors":"B. Lembcke","doi":"10.1159/000380833","DOIUrl":"https://doi.org/10.1159/000380833","url":null,"abstract":"Background: While detailed history, physical examination, and laboratory tests are of great importance when examining a patient with diverticular disease, they are not sufficient to diagnose (or stratify) diverticulitis without cross-sectional imaging (ultrasonography (US), computed tomography (CT)). Methods: Qualified US has diagnostic value equipotent to qualified CT, follows relevant legislation for radiation exposure protection, and is frequently effectual for diagnosis. Furthermore, its unsurpassed resolution allows detailed investigation down to the histological level. Subsequently, US is considered the first choice of imaging in diverticular disease. Vice versa, CT has definite indications in unclear/discrepant situations or insufficient US performance. Results: Endoscopy is not required for the diagnosis of diverticulitis and shall not be performed in the acute attack. Colonoscopy, however, is warranted after healing of acute diverticulitis, prior to elective surgery, and in atypical cases suggesting other diagnoses. Perforation/abscess must be excluded before colonoscopy. Conclusion: Reliable diagnosis is fundamental for surgical, interventional, and conservative treatment of the different presentations of diverticular disease. Not only complications of acute diverticulitis but also a number of differential diagnoses must be considered. For an adequate surgical strategy, correct stratification of complications is mandatory. Subsequently, in the light of currently validated diagnostic techniques, the consensus conference of the German Societies of Gastroenterology (DGVS) and of Visceral Surgery (DGAV) has passed a new classification of diverticulitis displaying the different facets of diverticular disease. This classification addresses different types (not stages) of the condition, and includes symptomatic diverticular disease (SUDD), largely resembling irritable bowel syndrome, as well as diverticular bleeding.","PeriodicalId":49114,"journal":{"name":"Viszeralmedizin","volume":"31 1","pages":"95 - 102"},"PeriodicalIF":0.0,"publicationDate":"2015-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000380833","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64777206","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: The optimal treatment of acute complicated diverticulitis is a matter of debate and has undergone significant changes. Currently, the main focus of surgical treatment concepts is on controlling the emergency situation triggered by acute complicated sigmoid diverticulitis through interventional and minimally invasive measures. Methods: This article presents the current data and recommendations on differentiated treatment of acute complicated sigmoid diverticulitis, which are also summarized in a decision tree. Results: In general, resection of the diverticular sigmoid is needed to treat acute complicated sigmoid diverticulitis, because without resection the recurrence rate is too high at 40%. Since the morbidity and mortality rates associated with emergency resection are extremely high, resulting in the creation of a stoma, efforts are made to control the acute situation through interventional and laparoscopic measures. Therefore, pericolic and pelvic abscesses (Hinchey stages I, II) are eliminated through percutaneous or laparoscopic drainage. Likewise, laparoscopic lavage and drainage are performed for purulent and feculent peritonitis (Hinchey stages III, IV). After elimination of the acute septic situation, interval elective sigmoid resection is conducted. If emergency resection cannot be avoided, it is performed, while taking account of the patient's overall condition, with primary anastomosis and a protective stoma or as discontinuity resection using Hartmann's procedure. Conclusion: Thanks to the progress made in interventional and laparoscopic treatment, differentiated concepts are now used to treat acute complicated sigmoid diverticulitis.
{"title":"Emergency Surgery for Acute Complicated Diverticulitis","authors":"F. Köckerling","doi":"10.1159/000378738","DOIUrl":"https://doi.org/10.1159/000378738","url":null,"abstract":"Background: The optimal treatment of acute complicated diverticulitis is a matter of debate and has undergone significant changes. Currently, the main focus of surgical treatment concepts is on controlling the emergency situation triggered by acute complicated sigmoid diverticulitis through interventional and minimally invasive measures. Methods: This article presents the current data and recommendations on differentiated treatment of acute complicated sigmoid diverticulitis, which are also summarized in a decision tree. Results: In general, resection of the diverticular sigmoid is needed to treat acute complicated sigmoid diverticulitis, because without resection the recurrence rate is too high at 40%. Since the morbidity and mortality rates associated with emergency resection are extremely high, resulting in the creation of a stoma, efforts are made to control the acute situation through interventional and laparoscopic measures. Therefore, pericolic and pelvic abscesses (Hinchey stages I, II) are eliminated through percutaneous or laparoscopic drainage. Likewise, laparoscopic lavage and drainage are performed for purulent and feculent peritonitis (Hinchey stages III, IV). After elimination of the acute septic situation, interval elective sigmoid resection is conducted. If emergency resection cannot be avoided, it is performed, while taking account of the patient's overall condition, with primary anastomosis and a protective stoma or as discontinuity resection using Hartmann's procedure. Conclusion: Thanks to the progress made in interventional and laparoscopic treatment, differentiated concepts are now used to treat acute complicated sigmoid diverticulitis.","PeriodicalId":49114,"journal":{"name":"Viszeralmedizin","volume":"31 1","pages":"107 - 110"},"PeriodicalIF":0.0,"publicationDate":"2015-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000378738","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64774959","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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