Colonic Diverticula - Symptoms

Based on clinical features, asymptomatic diverticula, uncomplicated diverticular disease, and diverticular disease with complications are distinguished.

Uncomplicated diverticular disease of the colon. For a long time, there was a notion that uncomplicated diverticular disease of the colon was asymptomatic. Work in recent decades indicates that most patients with uncomplicated diverticula have clinical manifestations. Diverticula were asymptomatic in only 14% of cases of uncomplicated diverticulosis and in 5% of all cases of their detection.

A characteristic symptom of uncomplicated diverticulosis of the colon is pain, the localization of which, as a rule, corresponds to the location of the diverticula, i.e., most often in the left lower quadrant. The pain is usually short-lived, recurrent, sometimes radiating back and down. It is often relieved after stool and the passage of gases. Constipation, mostly not of a persistent nature, transient diarrhea, often alternating, are often observed. Many patients experience flatulence. Less often, patients complain of the lack of a feeling of complete emptying of the intestine after defecation. In some cases, abdominal palpation reveals spastic contraction and pain in the affected area of the intestine.

Thus, uncomplicated diverticular disease of the colon has symptoms of functional disorders. Relatively rarely, it is asymptomatic.

Complications of diverticular disease of the colon. Diverticulitis occupies a special place. Diverticula in the colon already at the time of their detection in most cases have signs of diverticulitis. Sometimes the first signs of the disease appear only with the development of the inflammatory process in the diverticula.

In the clinical picture of diverticulitis, the main symptom is abdominal pain, especially in the left lower quadrant, which is reported by almost all patients. Transient or constant constipation, intermittent diarrhea or their alternation are common. Flatulence is often observed. Multiple bowel movements, tenesmus, and the lack of a feeling of complete emptying of the intestine after stool are noted by patients with diverticulitis of the sigmoid. Pathological impurities in the feces are possible (mucus, blood, and less often pus). Dysuria is sometimes observed, which is caused by the spread of inflammation from the colon to the bladder or the formation of adhesions with it.

General manifestations of inflammation are characteristic: increased temperature, chills, increased ESR, hyperleukocytosis with a shift to band cells.

An exacerbation of chronic diverticulitis is sometimes accompanied by nausea, vomiting, general weakness, loss of appetite, and weight loss.

During physical examination of chronic diverticulitis during an exacerbation, a symptom of percussion pain in a limited area and muscle tension may be detected. Deep palpation in almost all cases, even outside of an exacerbation, reveals pain in the affected segment of the intestine. Often, a compaction of the intestinal area is palpated, sometimes a tumor-like formation, unclearly delimited, with an uneven surface.

Outside the period of exacerbation of chronic diverticulitis, the patients' ability to work is preserved.

There are 3 variants of the clinical course of chronic diverticulitis: latent, colitis-like and in the form of “abdominal crises”.

Latent variant. Diverticulitis can last for a long time without noticeable impairment of work capacity. However, there are certain anamnestic and diagnostic signs: episodic pain, stool disorders, flatulence.

Colitis-like variant. Abdominal pain is a frequent concern. There are severe constipation or diarrhea, and bloating is often a concern. Mucus and blood often appear in the stool. Body temperature sometimes rises, usually to subfebrile. Pain during palpation of the affected area of the colon becomes severe.

Variant in the form of "abdominal crises". Most often, chronic diverticulitis occurs with attacks of abdominal pain, reminiscent of an acute abdominal disease. Characteristic is a sudden "onset" of the disease, and subsequently its exacerbations. Local pain in the abdomen appears, increasing in intensity, which subsequently becomes widespread. The temperature rises, increasing over several hours - 2 days, often chills. Constipation becomes more persistent or diarrhea appears, flatulence occurs. An admixture of mucus, blood, sometimes pus appears in the feces. Symptoms of peritoneal irritation can be determined. The affected area of the intestine becomes sharply painful upon palpation. Subsequently, an infiltrate can be felt. With the reverse development of the inflammatory process, the clinical manifestations gradually subside.

This variant of diverticulitis is described as "left-sided appendicitis" due to the similarity of its symptoms to those of appendicitis. It is in this variant of chronic diverticulitis that microperforation of the diverticulum or the formation of intraintestinal microabscesses often occurs.

Chronic diverticulitis is characterized by a persistent course. Exacerbation of chronic diverticulitis is stopped rather quickly with timely treatment, however, a tendency to relapse is typical.

Intestinal bleeding in diverticular disease of the colon occurs in 9-38% of cases. The high frequency of this complication is due to the proximity of diverticula to blood vessels. The source of bleeding may also be swollen mucous membrane and granulation tissue. Bleeding most often occurs with diverticulitis, but it is also possible in the absence of inflammation due to trauma to a blood vessel. Atherosclerosis and hypertension, which often accompany diverticular disease, favor bleeding.

Intestinal bleeding can be massive (2-6%) and (more often) scanty, in the form of unchanged blood and tarry stool, single and recurrent. Bleeding is often the first manifestation of the disease.

Intestinal obstruction. The incidence of intestinal obstruction, according to various authors, varies from 4 to 42%. Intestinal obstruction may be caused by the development of an inflammatory infiltrate that narrows or compresses the intestine, an adhesive process that leads to deformation of the intestine or its mesentery. Sometimes it occurs with chronic diverticulitis as a result of smooth muscle spasm in combination with reversible inflammatory changes in the intestinal wall.

When a narrowing of a section of the intestine develops due to diverticulitis, differential diagnostics with a neoplasm may be difficult. The tumor conglomerate sometimes also includes loops of the small intestine, so in some cases small intestinal obstruction develops.

Diverticulum perforation. According to most researchers, diverticulum perforation is the most common complication of diverticulitis. It is caused by the spread of the inflammatory process deep into the diverticulum wall and increased intraintestinal pressure. Of great importance is the pressure of fecal matter, which can lead to necrosis of the diverticulum wall. Perforation is also possible in the absence of inflammation in the diverticulum due to a sharp increase in pressure in the intestinal lumen.

Free and covered perforation of the diverticulum occurs. With slow progression of inflammation, the serous membrane "sticks" to the surrounding organs, and covered perforation occurs. In chronic diverticulitis, microperforations are common, often secondarily covered, not always diagnosed even with laparoscopy. Such small perforations are clinically manifested as acute or exacerbation of chronic diverticulitis.

Peritonitis. Diverticulitis as a cause of peritonitis is fourth after appendicitis, perforated gastric and duodenal ulcers, and ileus. The development of peritonitis may be associated with perforation of a diverticulum, rupture of an abscess, or spread of inflammation beyond the colon.

Abscesses (frequency 3-21%) may occur inside the intestinal wall due to inflammation and swelling of the neck of an incomplete pseudodiverticulum and its obstruction. More often they are formed as a result of a covered perforation of the diverticulum. In case of a diverticular abscess, a tumor-like formation is often palpated, which must be differentiated from carcinoma.

Fistulas (frequency 1-23%) are formed by perforation of a diverticulum and by a rupture of an abscess. The most common are intestinal-vesical fistulas. They are more common in men, since in women the uterus is located between the intestine and the bladder. Less common are fistulas with the ureter, vagina, uterus, other parts of the large intestine, small intestine, and intestinal-cutaneous fistulas. Diverticulitis of the right half of the large intestine is rarely complicated by the formation of a fistula with the gallbladder.

Perivisseritis. Chronic diverticulitis often leads to the development of perivisceritis. This is facilitated by the thin wall of the false diverticulum. However, it is impossible to judge the true prevalence of this complication, since pericolitis phenomena are detected relatively rarely during instrumental examination and laparotomy.

Rare complications. In diverticulitis, purulent phlebitis of the portal vein and its branches with abscess formation in the liver, lungs, brain, sepsis, torsion of the diverticulum, massive bleeding from the iliac artery eroded by a diverticular abscess are occasionally encountered.

Associated diseases. Diverticular disease of the colon is often combined with hernias of the anterior abdominal wall, varicose veins of the lower extremities, diverticula of the small intestine, bladder, hemorrhoids. It is often combined with calculous cholecystitis and hernia of the esophageal opening of the diaphragm - Sent's triad. Apparently, there are common factors predisposing to the occurrence of each of these diseases. These include, on the one hand, increased intra-abdominal pressure, contributing to the development of both diverticula and hernia of the esophageal opening of the diaphragm, and on the other hand, cholestasis, which favors the formation of stones. The combination of diverticular disease with colon cancer, according to most researchers, does not exceed the frequency of the latter among elderly and old people. Some authors have often described a combination of diverticular disease of the colon with polycystic kidney disease and bronchiectasis.

The prognosis for diverticular disease is favorable in most cases, but it can lead to the development of severe, even life-threatening complications. This is explained not only by the severity of the complications themselves, but also by the predominant lesion of elderly and senile people, who often have concomitant diseases, and lower resistance in this age group.

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