Treatment of intestinal diverticulosis

Treatment of intestinal diverticulosis is aimed at improving the quality of life of patients with diverticular disease, for this it is necessary to relieve symptoms.

Timely treatment of acute diverticulitis to prevent life-threatening complications. The criteria for the effectiveness of diverticulitis treatment are achieving clinical and laboratory remission or at least stopping the acute inflammatory process and pain syndrome. Prevention of complications of diverticular disease.

Indications for hospitalization

Diverticulosis of the intestine without diverticulitis or without exacerbation of chronic diverticulitis is treated on an outpatient basis. The need for hospitalization arises in the following cases:

• acute diverticulitis (exacerbation of chronic diverticulitis);
• severe intoxication;
• inability to take food through the mouth;
• the patient is over 85 years old;
• severe concomitant diseases;
• high fever (39-41 °C);
• symptoms of peritoneal irritation;
• pronounced leukocytosis - more than 15x 10 ⁹ /l (in old age it may not be present);
• the presence of immunosuppression in the patient, including iatrogenic, for example, due to taking glucocorticoids.

Indications for specialist consultation

If complications of intestinal diverticulosis develop, it is necessary to involve a surgeon both for consultations and to determine indications for surgical treatment.

Non-drug treatment of intestinal diverticulosis

Mode

It is necessary to refuse cleansing enemas and, if possible, laxatives. A beneficial effect is provided by the expansion of physical activity due to the acceleration of the passage of intestinal contents and the reduction of pressure in the intestinal lumen.

Diet

Patients with uncomplicated diverticular disease are recommended to enrich their diet with dietary fiber (except for very coarse fiber: turnips, radishes, horseradish, pineapples, persimmons) - more than 32 g/day, since dietary fiber reduces pressure in the lumen of the colon.

If such a diet is poorly tolerated, it is recommended to eat foods rich in dietary fiber in small portions, chopped, and vegetables after cooking. It is recommended to limit gas-forming foods (cabbage, grapes, etc.), and exclude legumes and carbonated drinks. It is necessary to drink a sufficient amount of liquid - 1.5-2 liters (in the absence of contraindications).

Eliminating foods containing small seeds and nuts is not currently recommended.

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Drug treatment of intestinal diverticulosis

Uncomplicated intestinal diverticulosis

The following groups of drugs are used on an outpatient basis for intestinal diverticulosis.

• Antispasmodics
• Calcium channel blockers: mebeverine (200 mg 2 times a day), pinaverium bromide (50 mg 3 times a day).
• Anticholinergics: hyoscine butibromide. platiphylline.
• Myotropic antispasmodics: papaverine, bencyclane or drotaverine chloride.

Prescription of antispasmodics leads to reduction of pain syndrome. Dose, duration and method of administration are selected individually.

Stool Regulators

Stimulant laxatives should be avoided as they may increase intestinal pressure and cause pain. Osmotic laxatives and agents that increase the volume of intestinal contents are recommended. An osmotic laxative for stool regulation is lactulose. The initial dose is 15-45 ml per day, the maintenance dose is 10-30 ml per day in one dose in the morning. The dose is adjusted after 2 days if there is no effect. Plantain seed coat is a preparation made from the seed coats of the Indian plantain Plantagoovata. It is recommended to take the drug in a dose of 2-6 sachets per day. The effect is due to softening of the intestinal contents and an increase in its volume. In case of diarrhea syndrome - astringents, adsorbents (dioctahedral smectite, bismuth preparations). In case of flatulence, adsorbents, simethicone are prescribed. Precautions: avoid using drugs of the morphine group and similar synthetic compounds that increase the tone of smooth muscles.

Acute diverticulitis

In case of acute diverticulitis or exacerbation of chronic diverticulitis, hospitalization in a surgical (proctological) hospital, infusion therapy with plasma-substituting and detoxifying solutions, and the administration of broad-spectrum antibacterial drugs that penetrate well into tissues and are active against intestinal microflora (second-generation cephalosporins, nitroimidazoles, fluoroquinolones, etc.) are recommended.

Stage 1 (beginning and at the height of inflammation) - 7-10 days. For 2-3 days, food intake is completely excluded and oral and parenteral rehydration is prescribed. The latter is preferable in severe conditions of the patient. After a few days, the diet is carefully expanded. Prescribing a diet enriched with dietary fiber is possible only after complete resolution of acute diverticulitis. In case of vomiting, bloating, the introduction of a nasogastric tube is indicated. Detoxification therapy is carried out. Antibiotics effective against gram-negative and anaerobic microflora are used. The following schemes can be used:

• monotherapy - second-generation cephalosporin or protected penicillin (the effectiveness of monotherapy, according to some studies, is not inferior to that of using several antibiotics);
• treatment with two antibiotics: a drug active against anaerobic microflora + aminoglycoside, third-generation cephalosporin or monobactam; treatment with three antibiotics: ampicillin, gentamicin and metronidazole.

If there is no effect from treatment after 2-3 days, the formation of an abscess should be excluded.

In case of a moderately expressed inflammatory process (absence of intoxication, signs of peritoneal irritation, normal or subfebrile body temperature), antibiotics are prescribed orally. The most convenient is amoxicillin + clavulanic acid (protected penicillin) orally at a dose of 875 mg every 12 hours.

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Drugs and dosages

Cefoxitin (second generation cephalosporin) - 2 g IV every 6 hours.

Ampicillin + sulbactam (protected penicillin) - 3 g IV every 6 hours.

Ticarcillin + clavulanic acid (protected penicillin) - 3.1 g IV every 6 hours.

Imipenem + cilastatin (p-lactam antibiotic) - 500 mg IV every 6 hours.

Metronidazole 500 mg IV every 6 hours in combination with (one of the options):

• gentamicin at a daily dose of 3-5 mg/kg, divided into 2~3 administrations;
• ceftriaxone at a dose of 1 g intravenously every 24 hours; ciprofloxacin at a dose of 400 mg intravenously every 12 hours.

Ampicillin at a dose of 2 g intravenously every 6 hours in combination with gentamicin at a daily dose of 3-5 mg/kg, divided into 2-3 administrations, and metronidazole 500 mg intravenously every 6 hours.

Antispasmodic drugs and anticholinergics are prescribed parenterally for pain. Regulation of bowel function is indicated: for constipation - vaseline oil (no longer than 5-7 days), macrogol, plantain seed coat; for diarrhea - adsorbents, astringents.

Stage 2 (inflammation subsides) - 7-10 days. The diet is gradually expanded. Antibacterial treatment is continued as indicated (in this case, a change of drug is mandatory). Intestinal motility is regulated, vitamin therapy is administered.

Stage 3 - maintenance therapy and observation. Carried out on an outpatient basis. A set of measures is indicated, similar to that in the treatment of diverticular disease outside of an exacerbation of diverticulitis.

Surgical treatment of intestinal diverticulosis

Surgical treatment of intestinal diverticulosis is indicated for complications of the disease that pose an immediate threat to the patient's life - perforation of the diverticulum into the abdominal cavity, intestinal obstruction, profuse bleeding, the presence of fistulas (interintestinal, intestinal-vesical, intestinal-vaginal), recurrent diverticulitis complicated by abscess formation. Treatment of intestinal diverticulosis is carried out in the surgical department.

Peri-intestinal abscess - expectant tactics (for abscesses less than 2 cm in size, located near the mesentery of the colon, conservative tactics are justified). Pelvic, retroperitoneal abscesses, peritonitis - indications for surgical treatment. In case of abscesses, percutaneous drainage under X-ray control is possible.

The choice of the surgical method in each specific case depends on a number of factors: the nature of the complications, the prevalence of the process, inflammatory changes in the diverticulum tissue, intestinal wall and surrounding tissues, the presence of perifocal inflammation or peritonitis. Concomitant diseases, often observed in elderly people, play a major role. It is preferable to perform a resection of the colon on a planned basis with simultaneous imposition of anastomosis. The operation is performed 6-12 weeks after the relief of an acute attack of diverticulitis.

Tactics of management

Asymptomatic intestinal diverticulosis, diagnosed by chance, does not require special treatment. In order to prevent the progression of the disease and prevent possible complications, the patient is recommended a diet rich in plant fiber.

In case of diverticulosis with pronounced symptoms, a complex of therapeutic measures is used: a laxative diet, antispasmodics, drugs that regulate the motor function of the intestine. In most patients with clinically expressed diverticular disease of the colon, conservative treatment of intestinal diverticulosis gives a lasting positive effect.

In case of diverticulitis, antibiotics, intestinal antiseptics, and osmotic laxatives are prescribed.

Further management of the patient

An annual medical examination and routine outpatient examination are indicated.

After resolution of acute diverticulitis, an examination is necessary to exclude other pathologies of the colon (primarily cancer, which is detected in 6% of patients with diverticular disease) - a colonoscopy is indicated 1 month after resolution of diverticulitis.

After resolution of diverticulitis, careful monitoring is necessary to exclude its complications (abscess, fistulas, intestinal stenosis): careful collection of anamnesis, if necessary - plain radiography of the abdominal cavity, irrigoscopy with barium enema, CT of the abdominal cavity.

When monitoring a patient with diverticular disease, it is necessary to promptly identify diverticulitis, the main clinical manifestations of which are abdominal pain and increased body temperature.

Patient education

The patient must be provided with complete information about his disease and warned about the signs and dangers of acute diverticulitis.

Detailed dietary recommendations should be given.

The patient should be advised to increase physical activity.