Diverticulitis and diverticulosis.
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BACKGROUND AND AIMS: MRI-based colonography is a new minimally invasive imaging modality to assess the colon and abdomen. This new method which is applied mainly for polyp screening could be an integrative approach for colonic diverticulitis assessment. This study evaluated the feasibility of MRI-based colonography to assess diverticulosis or diverticulitis. PATIENTS AND METHODS: Fourteen consecutive patients with clinically suspected diverticulitis were examined by MRI colonography on a 1.5-T scanner. All patients underwent abdominal CT as gold standard. N-Butyl-scopalamin was given intravenously to reduce bowel peristalsis. After rectal administration of a T1-positive enema T1- and T2-weighted acquisitions with additional intravenous contrast were obtained. A 3D FLASH sequence was acquired for virtual colonography. The results were compared with CT and biological parameters such as white blood cell count and C-reactive protein. RESULTS: Of 56 bowel segments (sigmoid colon, descending colon, transverse colon, ascending colon) in all 14 patients 54 were assessed to have good to fair image quality. Having CT as standard of reference, all sigmoid diverticula were diagnosed based on MRI. Inflammation as judged by CT was identically assessed on MRI. 3D models of the colon revealed further diverticula in the remaining colon; additionally, the 3D models gave a comprehensive image for surgical planning. CONCLUSION: In our preliminary study MRI colonography revealed the same diagnosis as CT in all patients without ionizing radiation. Additionally, 3D-rendered models and virtual colonoscopy can be performed. This comprehensive 3D models could replace presurgical planning barium enema with concurrent assessment of the residual colon.
Diverticulosis of the colon is common in the descending and sigmoid part; the right colon is rarely involved. Inflammation of perforation of a cecal diverticulum is an uncommon condition that mimics acute appendicitis. The correct diagnosis is mostly made after operative exploration. Four cases were surgically treated between 1994 and 1995. Because of the severe inflammation, ileocecal resection or right hemicolectomy was necessary; in one case we performed a local excision. After removal of the inflamed mass the postoperative healing was uncomplicated. A malignancy could be histologically excluded in all cases. As in sigmoid diverticulitis, early resection seems to be a safe operative therapy. Laparoscopy can show the correct diagnosis before the laparotomy is carried out. Preoperative diagnostic measures, differential diagnosis and possible surgical procedures are discussed.
Spastic colon disease is a syndrome consisting of abdominal pain and abnormal bowel function associated with thickening of the circular muscle layer of the colon. The condition may be related to changes in intraluminal pressure associated with a lifelong low residue diet. Radiologic features include thickening, crowding, irregularity, and distortion of the interhaustral folds of the sigmoid colon, which in the past have been incorrectly considered to be manifestations of acute diverticulitis. Spastic colon disease leads to diverticulosis which develops because of mucosal herniations through the weakened colonic wall. When a diverticulum perforates, acute diverticulitis ensues. Depending on how the subsequent inflammatory response is contained, a mural abscess, colonic narrowing or obstruction, an intra-abdominal abscess, or a fistula may occur and be demonstrated on barium enema examination.
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Colonic diverticula result from herniation of the mucosa through weak spots in the muscular wall. Clinically manifested diverticulitis has been thought to have its pathologic basis in an abscessed diverticulum obstructed by a fecalith, but studies of resected sigmoids have failed to produce evidence to support this view. Instead, the outstanding lesion was found to be a perforation in the fundus of a diverticulum, with surrounding peridiverticular or pericolic inflammation. Another surprising finding in pathologic studies was that one out of three sigmoids resected for "diverticulitis" showed no inflammation in or around the diverticula, but the wall of the sigmoid was impressively thickened. This type of diverticulosis, which is frequently symptomatic, has been referred to as painful diverticular disease or spastic colon diverticulosis. Diverticula without muscle thickening are usually asymptomatic, and the condition is referred to as diverticulosis or simple massed diverticulosis. It is uncertain whether the two types have a similar pathogenesis. High intrasigmoid pressures, abnormalities of sigmoid musculature, low-fiber diet, and psychologic stress are thought to be important factors in the formation of diverticula.
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Over the last 100 years, the prevalence and incidence of diverticulosis and diverticular disease have increased dramatically in western industrialized countries. The main reasons for this are considered to be changes in eating habits, and the increasing age of the population. Conservative treatment of diverticulitis is an initial period of fasting and antibiotic treatment. For recurrence prevention, a fiber-rich diet is recommended. Studies providing evidence in support of the general recommendation of recurrence prophylaxis with poorly absorbed antibiotics, mesalazine or probiotics are to date not adequate. Elective prophylactic sigmoid resection is to be recommended following an episode of diverticulitis with complications, and after an episode of uncomplicated diverticulitis in long-term immunosuppressed patients who have already had an attack. Elective sigmoid resection after a healed second attack of uncomplicated diverticulitis is controversial.
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Alterations in the colon wall, motility disorders, and certain nutritional habits are the essential factors in the development of colon diverticula. Thus, with advancing age this results in a high incidence in Western industrialized countries. The clinical picture is usually one of symptom-free diverticulosis. Diverticular disease can be associated with minor symptoms, but in complicated cases with diverticulitis and diverticular hemorrhage, it is potentially fatal. Further complications include abscess formation, fistula development, and obstruction. Barium double-contrast imaging exhibits the highest diagnostic sensitivity in diverticulosis but is contraindicated in cases of suspected complicated diverticular disease due to the danger of perforation. In these instances, sonography, computed tomography, or magnetic resonance imaging are performed. For diverticular hemorrhage, coloscopy not only represents a possible diagnostic tool but also a therapeutic option for various techniques of hemostasis. Treatment of diverticulitis and its complications requires careful consideration of conservative and surgical approaches and close interdisciplinary cooperation.
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The cause of colonic diverticula is myostatic spasm. A low-residue diet contributes to this state as transit time through the bowel is slowed. Information gathered in 102 cases was analysed. The smooth muscle architecture of specially prepared operative specimens of diverticulosis were examined. In every case an asymmetric contracture of the smooth musculature led to the formation of gaps. Here the mucosa and muscularis mucosae can protrude through the bowel wall. The muscular spasm is responsible for incarceration of the diverticula. Inflammatory diverticulitis is compared to appendicitis.
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