Diagnosis of intestinal diverticulosis

[1], [2], [3], [4], [5], [6], [7]

Indications for consulting other specialists

• Surgeon-coloproctologist - if there are indications for surgical treatment.
• Gynecologist, urologist - when conducting a differential diagnosis with gynecological (urological) pathology.

[8], [9], [10], [11], [12], [13]

Laboratory diagnosis of intestinal diverticulosis

In case of uncomplicated diverticulosis, a laboratory examination is carried out when a diagnosis is made to exclude other diseases. Suspicion of the development of complications dictates the need for detailed laboratory examination.

[14], [15], [16]

Mandatory laboratory tests

[17], [18], [19], [20]

Single

• Complete blood count : leukocytosis with a leukocyte shift to the left is possible with diverticulosis, an increase in the ESR. Nevertheless normal blood leukocytes do not exclude the presence of acute diverticulitis. In the case of bleeding - signs of iron deficiency anemia (decreased content of Hemoglobin, quantity erythrocytes, color index).
• General urinalysis - to exclude damage to the urinary tract, such as urinary infection, pyelonephritis, urolithiasis (as part of a differential diagnosis). With the formation of an enteric bladder fistula, it is possible to detect leukocytes, erythrocytes, components of the intestinal contents, bacteria specific for the intestines in urine.
• Coprogram - if complications develop, it is possible to detect signs confirming the presence of inflammation: neutrophilic leukocytes, a large number of macrophages, desquamous epithelium.

analysis of feces for occult blood is positive for microperforation and for bleeding.

[21], [22], [23], [24], [25]

Additional laboratory tests

In women of childbearing age, it is necessary to conduct a pregnancy test (to exclude ectopic pregnancy). With recent antibiotic therapy, pseudomembranous colitis should be eliminated by detecting Clostridium difficile toxin in the feces .

In the presence of hypochromic anemia - determination of the concentration of serum iron, OZHSS, the average hemoglobin in the erythrocyte.

Coagulogram, hematocrit with suspected intestinal bleeding.

Carcinoembryonic antigen for suspected tumor.

In the dynamics (in the case of changes in the first study):

• clinical blood test;
• the concentration of serum iron, OZHSS, the average hemoglobin content in the erythrocyte;
• analysis of fecal occult blood;
• general urine analysis.

[26], [27]

Instrumental diagnosis of intestinal diverticulosis

It is necessary to confirm the presence of the diverticulum (diverticula) with the help of imaging methods.

[28], [29], [30], [31], [32], [33], [34], [35]

Mandatory survey methods

Colonoscopy is the method of choice for uncomplicated diverticulosis. The characteristic endoscopic signs of diverticulosis are the presence of single or multiple estuaries of diverticula in the intestinal wall. A blood vessel is often found near the mouth of the diverticulum. In the area of the diverticulum determine the increased tone and stiffness of the intestinal wall. When the diverticulum is in proximity to the physiological sphincters, the latter are spasmized and open with difficulty. In addition to detecting the diverticulum itself, a colonoscopy allows visualization of the source of intestinal bleeding.

If you suspect a complication of colonoscopy is associated with the risk of perforation during the discharge of air into the large intestine, therefore, preference is given to CT scan of the abdominal cavity.

All patients with suspected complicated diverticulosis should be undergoing radiographic examination of the abdominal cavity (standing and lying) to exclude the perforation of the diverticulum and intestinal obstruction. Pneumoperitoneum due to perforation is found in 3-12% of patients with acute diverticulitis.

Ultrasound examination of the abdominal organs is used as an auxiliary method, when the interpretation of the findings when using other methods is ambiguous. Ultrasound is especially indicated in cases of suspected acute diverticulitis (exacerbation of chronic), acute abdomen, in the presence of infiltration in the abdominal cavity. Detect signs of diverticulitis - local thickening of the intestinal wall, edema, tenderness of the affected intestine in the study. According to indications, ultrasound of the bladder, kidneys, and genitals is performed. Contrast X-ray examination.

enema irrigoscopy is performed to detect colon diverticula (with this method, the risk of diagnostic errors is not excluded). Colon diverticulums can also be detected by oral contrast study 24-72 hours after ingesting barium suspension, but this method is less informative than irrigoscopy.

X-ray examination of the small intestine is carried out with suspected presence of diverticula in it. To diagnose the Mekkel diverticulum, barium is injected through a probe for a bunch of Treitz.

CT scan of the abdominal cavity is a method of choice in case of suspected complications of diverticular disease, which allows to evaluate not only changes in the lumen (the possibility of barberry enema), but also characterize the prevalence of the inflammatory process (intramural, extramural lesions, involvement of adjacent organs); The method showed better sensitivity and specificity for detecting acute diverticulitis compared with irrigoscopy.

With a previous diagnosis of colon diverticulosis and suspicion at the time of the examination for acute diverticulitis, irrigoscopy and colonoscopy are contraindicated because of the risk of perforation. The study is conducted on the background of subsiding of the inflammatory process - usually in 7-10 days after the start of treatment.

[36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46]

Additional survey methods

• Cystoscopy and cystography - for the diagnosis of cystic and intestinal fistulas.
• Intravenous urography can detect involvement in the inflammatory process of the ureters.
• Angiography is a diagnostic method used for bleeding from the diverticulum. It is possible to carry out therapeutic measures through embolization of the bleeding vessel.
• Fistulography - to identify fistula.

If other research methods are not informative, it is necessary to discuss the feasibility of laparoscopy, which allows more to exclude other diseases than to establish the diagnosis of complicated diverticular disease. It should be borne in mind that laparoscopy itself may be fraught with iatrogenic complications.

If a tumor is suspected during an endoscopic examination of the intestine, a targeted biopsy is performed followed by histological and cytological examination of biopsy specimens.

[47], [48], [49], [50], [51]

Differential diagnosis of intestinal diverticulosis

[52], [53], [54], [55], [56], [57], [58], [59], [60], [61]

Irritable Bowel Syndrome

In case of irritable bowel syndrome during irrigoscopy and colonoscopy, there are no organic changes in the colon.

[62], [63], [64], [65], [66]

Inflammatory diseases of the colon

Crohn's disease: characteristic abdominal pain, usually in the right lower quadrant of the abdomen, diarrhea, weight loss. Extraintestinal manifestations are possible: arthritis, skin lesions, uveitis.

Pseudomembranous colitis: typical abdominal pain, including colicky, combined with diarrhea, nausea, vomiting and fever. Intestinal damage is due to recent antibiotic therapy or hospital infection. For differential diascosis, a study of feces for Clostridium difficile toxin is necessary .

Acute appendicitis: Kocher's positive symptom, subfebrile, anorexia, single vomiting, symptoms of peritoneal irritation in the right potdoshny area are possible. In general, the clinical symptoms resemble those of diverticulitis. The appendicular abscess in a clinical picture resembles an abscess that complicates the course of diverticulosis. Nevertheless, left- and not right-sided manifestations are characteristic of diverticular disease.

[67], [68], [69], [70], [71], [72], [73]

Celiakia

Diarrhea (in response to products with gluten) and weight loss are typical. This symptom can be combined with iron or B12-deficiency anemia and osteoporosis.

[74], [75]

Colorectal cancer

The progressive symptoms of partial intestinal obstruction are characteristic: periodically arising abdominal pain, nausea, vomiting, constipation, diarrhea. Gastrointestinal bleeding, formation of fistulas penetrating into adjacent organs are possible. Typical weight loss and anemia. Endoscopic examinations are required for diagnosis.

[76], [77], [78], [79], [80]

Ischemic colitis

Pain in the lower abdomen, often colicky, accompanied by diarrhea with blood in the stool, nausea, vomiting, fever.

Additionally, in the differential diagnosis, gastric ulcer or duodenal ulcer, complicated by bleeding or perforation, ovarian cysts and torsion, ovarian abscesses, ectopic pregnancy, urolithiasis, acute pyelonephritis or exacerbation of chronic pyelonephritis must be kept in mind.

[81], [82], [83], [84], [85]