Complicated diverticular disease: case report
Abstract
Diverticulosis of the left colon is an increasingly common pathology in Western countries. Its prevalence is increasing throughout the world, which is associated with changes in conditions and lifestyle (1-5). This pathology is more typical for older age groups, but in recent years there has been an intense increase in the incidence rate at a younger age (2). The most common characteristic of diverticular bowel disease is asymptomatic flow (80% of cases). In 5–20% of patients with colon diverticulosis, the disease becomes a diverticular disease, and complications develop in 15% of cases. Diverticulitis, as a complication of colon diverticular disease, comes first. In general, the complicated course of the disease is 75%, while the perforation of the diverticulum is the 4th in frequency among the causes of emergency surgery after acute appendicitis, perforative gastroduodenal ulcer and intestinal obstruction, as well as the 3rd in the frequency among the causes of intestinal stems. The frequency of formation of intra-abdominal abscess or the development of peritonitis with diverticular disease is 3.5-4 cases per 100 thousand people per year (2,3). Also, diverticula are one of the causes of colonic bleeding. However, when making decisions on the diagnosis and treatment of a complicated course of diverticular disease, specialists are more often guided by their own preferences rather than by evidence-based medicine, which is explained by the lack of modern scientific work of a high level of evidence on this issue.
Keywords: diverticulitis, diverticular disease, perforation
On October 14, 2018, a self-referred 73-years-old patient admitted the outpatient unit of the State Budgetary Healthcare Institution of the Arkhangelsk Oblast ‘Severodvinsk Municipal Clinical Emergency Hospital No. 2’ with complaints on pain in the iliac region on the right 3 days after the disease onset.
Upon examination, the patient’s state was satisfactory with heart rate of 75 bpm and stable haemodinamics. Vesicular breathing, no rales, respiratory rate of 16 bpm. Clear, wet tongue. Abdomen not bloated, involved in breathing, soft, tender in the iliac region on the right with positive peritoneal signs (Mendel signs, Voskresenskiy signs) with negative Blumberg's sign. The patient has a history of surgery, namely, bilateral herniotomy due to bilateral inguinal hernia
The blood test showed the following parameters: leukocytes - 10.1× 109/l, С-reactive protein – 183 mg/l.
CT of the abdominal cavity and retroperitoneal space (Figure 1): Sigmoid colon in the iliac region on the right had signs of marked inflammatory changes such as unevenly thickened wall up to 6 mm, multiple gas bubbles parietally, infiltrated surrounded subcutaneous tissue (gas bubbles in it cannot be excluded).
Conclusion: Acute sigmoiditis, perforation is not excluded.
Diagnostic laparoscopy was carried out which the following findings: sigmoid colon elongated, located in the iliac region on the right, immobilised, fixed within this region with the area of necrosis on its wall. Conversion to midline laparotomy: sigmoid colon loop located in the iliac region on the right; a diverticulum branched from it entering the right inguinal canal through dilated internal inguinal ring along with the adjacent sigmoid colon wall with the signs of necrosis. Removing of diverticulum from the inguinal canal was not feasible. Conversion to the right inguinal region was carried out, the hernia sac was isolated from adhesions in the initial part of the inguinal canal and opened. In the sac, a top of the diverticulum was found among adhesions fused with the inguinal sac walls. Adheolysis and herniotomy were carried out followed by plastic repair of the inguinal canal with local tissues. Then resection of the pathological part of sigmoid colon with diverticulum was performed through the abdominal cavity (Figure 2).
Conclusion
Recently, diverticular disease of colon, especially of its left half, has become one of the most acute issues of abdominal urgent surgery. Increased proportion of the elderly population and progressing incidence of diverticulosis as well as its severe complications due to perforation and diverticular abscess formation encourages more focused attention to this problem. At present, a number of approaches to complicated diverticulitis diagnostics and treatment have become irrelevant and require reconsideration. Today, the leading role in diagnostics of diverticulitis complications belongs to CT. The management is based on the imaging data and minimally invasive procedures, including laparoscopic and endoscopic surgeries are becoming increasingly popular. However, in special cases when the inflamed diverticulum location is anatomically atypical, the only method of complicated diverticulitis diagnostics and treatment is laparotomy with abdominoscopy and removal of the infection source as demonstrated by our findings.
Informed Consent
Written informed consent was obtained from patients who participated in this study.
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