Colonic diverticulum in the elderly
Introduction
Introduction to colonic diverticulum in the elderly Colonic diverticulum refers to a diverticulum-like lesion formed by the removal of the colonic mucosa through the defect of the muscular layer of the intestinal wall. It can occur in any part of the intestine. The best part is the colon, followed by the duodenum. Typical diverticulitis symptoms include abdominal pain, fever, nausea, vomiting, bloating, constipation, and diarrhea. Because the sigmoid colon is the most common part of the diverticulum, abdominal pain is mostly in the lower abdomen, especially in the lower left abdomen. It can also be manifested in the lower right abdomen or in the diverticulum. The degree of pain in the right lower abdomen varies depending on the degree of inflammation. basic knowledge The proportion of illness: 0.002% Susceptible people: the elderly Mode of infection: non-infectious Complications: peritonitis abdominal abscess intestinal obstruction constipation
Cause
The cause of colonic diverticulum in the elderly
Colonic motor dysfunction (40%)
In the colon, the intestinal wall between the colonic bands maintains tension by the ring muscles, so that the blood vessels entering the intestinal wall constitute a defect in the ring muscle, which becomes the weak link. Intestinal hyperbaric state caused by colonic motor dysfunction and structural defects on the intestinal wall, potential weak parts of the intestinal lumen are likely to form diverticulum where the blood vessels enter the colon wall.
Collagen fiber changes (15%)
The collagen fibers in the colonic ring muscle are cross-distributed, which maintains the tension of the colon wall. As the age increases, the collagen fibers inside the colon cavity become thinner, the action of elastin fibers decreases, and the elasticity and tension of the colon wall decrease. Therefore, the narrowest and most hypertrophic sigmoid colon is a predilection site for the diverticulum.
Other factors (15%)
Temporary intestinal obstruction, constipation, intestinal fistula, drugs (intestinal pressure can be as high as 12kPa when taking opium) can cause the disease to increase due to increased intestinal pressure.
Pathogenesis
The composition of the wall of the colonic diverticulum consists of the colonic mucosa of the colon and the serosa that is covered, but does not contain the muscular layer, so it is actually a pseudo-diverticula with different calibers ranging from a few millimeters to several centimeters, diverticulum and intestines. The cavity often communicates through a narrow pore, and the contents of the intestine and gas can also enter the diverticulum without being easily discharged. Therefore, diverticulitis is often caused by poor drainage, as well as peripheral inflammation, perforation, peritonitis, abdominal abscess, intestinal fistula and bleeding. Severe complications, inflammation may be acute or chronic according to the length of the disease, and the development of inflammation may be due to intestinal wall and surrounding tissue edema, thickening, fibrosis and other pathological changes secondary to intestinal stenosis, And lead to varying degrees of intestinal obstruction.
Prevention
Elderly colonic diverticulosis prevention
1. Preventive measures
Primary prevention: prevention of the cause, timely treatment of factors that may cause increased intestinal pressure, such as temporary intestinal obstruction, constipation, paralysis, drugs, etc., timely release of obstruction, smooth stool, relieve intestinal cramps, avoid taking opium And other drugs.
Secondary prevention: early identification of diverticulum symptoms, early diagnosis of secondary prevention, typical diverticulitis diagnosis according to symptoms and signs, while the elderly, hormone-dependent and immunodeficiency patients are unresponsive, symptoms are not typical, feasible colonoscopy, abdominal plain film Or barium enema examination.
Tertiary prevention: Most of the diverticulum occurs in the elderly, and its prevention and prevention of complications are tertiary prevention.
2. Risk factors and interventions
(1) Risk factors: Temporary intestinal obstruction, constipation, intestinal fistula, and drugs can increase the intestinal pressure, and the mucous membrane can be exuded through the weak part of the intestinal wall.
(2) Interventions: Choose a high-fiber diet, such as wheat bran, to avoid factors that may cause increased intestinal pressure.
3. Social intervention
Health education for patients, changing eating habits and bad habits.
Complication
Elderly colonic complication Complications peritonitis abdominal abscess intestinal obstruction constipation
The main complications of colonic diverticulitis are:
1 perforation: The patient presented with localized peritonitis, diffuse peritonitis or abdominal abscess.
2 bleeding: more than the inflammatory reaction of the basal part of the diverticulum caused by a small amount of bleeding, old, patients with arteriosclerosis, although diverticulitis is not serious may also cause major bleeding, 10% to 30% of patients with diverticulosis combined with intestinal bleeding, is 3 % ~ 5% of the most common causes of fatal lower gastrointestinal bleeding in the elderly.
3: It is the result of colonic diverticulitis and surrounding visceral or chronic perforation. Abscess ulceration can form internal hemorrhoids between the small intestine, uterus, vagina and bladder, or form an external hemorrhoid between the abdominal wall and the abdominal wall. If the colon is connected to the bladder and ureter, It can cause dysuria, pneumoconiosis and urinary tract infections. Colonoscopy can be distinguished from ulcers, granuloma, colitis and cancer.
4 intestinal obstruction: usually subacute or chronic diverticulitis caused by narrowing of the narrowing of the intestinal fibrosis, patients often have recurrent left lower abdominal pain and progressive exacerbation of constipation, in addition, due to acute inflammation and abscess formation When the intestinal lumen is blocked, it causes acute colonic obstruction or acute intestinal obstruction due to adhesion of the inflamed colon to a small intestine.
Symptom
Colonic diverticulum symptoms in the elderly Common symptoms Colonic diverticulum abdominal pain, bloating, diarrhea, diarrhea, nausea, bloody constipation, lower abdominal pain, intestinal dysfunction
About 90% of patients with diverticulosis often have no clinical symptoms if they do not have diverticulitis. They are found by chance when they are examined by other digestive diseases. They may have mild symptoms and are not characteristic. They often do not attract the attention of patients. Sometimes It may also be treated only as a digestive tract inflammation without considering the diagnosis of this disease. Typical diverticulitis symptoms include abdominal pain, fever, nausea, vomiting, bloating, constipation, diarrhea, because the sigmoid colon is the most common part of the diverticulum, and abdominal pain is especially in the lower abdomen. It is the left lower abdomen. It can also be expressed in the lower abdomen midline or in the diverticulum. The degree of pain in the right lower abdomen varies depending on the degree of inflammation. During physical examination, muscle tension can be found locally, and sometimes inflammatory masses can be touched. Similar to appendicitis, some people call it "left appendicitis". Sometimes patients can show lower right abdomen pain. It is more important to distinguish it from appendicitis. Colonoscopy can see changes in intestinal mucosa, edema, etc. After a period of intestinal congestion, said sentinel sputum, barium enema examination may show that the intestine is a segmental hernia, mucosal edema, fixed to the intestine Stenosis, etc., but some people think that the acute inflammatory phase is not suitable for colonoscopy, so as not to aggravate the disease caused by intestinal rupture, sometimes the sigmoid colon in the long intestine is not easy to distinguish with obstructive colon cancer, at this time, more advocated fiberoptic colonoscopy, Typical diverticulitis is diagnosed according to symptoms and signs, while in the elderly, patients with hormone-dependent and immunodeficiency are unresponsive and the symptoms are not typical.
Examine
Examination of colonic diverticulum in the elderly
When the diverticulum is bladder spasm, a large amount of red, white blood cells, and white blood cells in the blood may appear in the urine.
1. Sigmoidoscopy: In addition to the direct observation of the mucosa of the intestinal wall, biopsy can also be used for pathological examination to determine whether the diverticulum has inflammation, bleeding, and other colorectal disorders, but if the bowel preparation is not satisfactory, or the operator Insufficient experience can easily lead to missed diagnosis. If there is too much gas injection or the colonoscopy does not enter the diverticulum cavity, there may be perforation.
2. Fibrous colonoscopy: the indications used are the same as the sigmoid colonoscopy, but because of its small damage and large observation range, there is a tendency to gradually replace the sigmoidoscopy.
3. Arteriography: diagnosis for patients with bleeding from diverticulitis.
4. B-ultrasound: can be used to observe diverticulitis with perforation or abscess mass formation, which helps to clearly locate and characterize.
Diagnosis
Diagnosis and diagnosis of colonic diverticulum in the elderly
Diagnostic criteria
For the elderly, obesity, plain constipation, colitis or frequent medication to cause chronic intestinal dysfunction, according to the above clinical manifestations to think of the diagnosis of diverticulosis, individual diagnosis of difficulties can be assisted by some imaging methods to confirm the diagnosis, while It should be identified with the following diseases.
1. Diverticulosis and diverticulitis: diverticulitis should have fever, peritoneal irritation, increased white blood cells, barium enema and CT examination can help to confirm the diagnosis.
2. Colon cancer: the age of the two diseases is similar, and the clinical manifestations are partially overlapped, which can cause intestinal obstruction, hemorrhage, perforation, fistula formation, barium enema help to identify, irregular mucosa, radiological features of intestinal filling defect Colonoscopy and mucosal biopsy are decisive for the diagnosis of colon cancer.
3. Ulcerative colitis: fever, increased white blood cells, abdominal pain, blood in the stool is a characteristic of ulcerative colitis. Endoscopic and X-ray findings show diffuse inflammation of the mucous membrane, edema, congestion, submucosal blood vessels are not transparent, and the disease is severe. Erosion, ulcers, pseudopolyps, residual mucosal atrophy between ulcers, smooth and hard lumen, narrowing of the lumen of the intestine, disappearance of the colonic pocket, etc.
4. Ischemic colitis: extensive arteriosclerosis and diverticulosis are common diseases in the elderly, and both diseases can occur simultaneously.
Differential diagnosis
Clinical should be differentiated from colitis, irritable bowel syndrome and colon cancer.
