資料來源. Acute Diverticulitis - StatPearls - NCBI Bookshelf
下面中文部分是直接用 google 翻譯的. 所以有些慣用的字詞與台灣醫界使用的不同.
例如腸梗阻
介紹
急性憩室炎是由憩室微穿孔引起的炎症。憩室是結腸壁的囊狀突起。約 10% 至 25% 的憩室病患者可出現憩室炎。憩室炎可以是簡單的，也可以是簡單的和復雜的。無並發症併發症的憩室炎沒有任何相關的並發症併發症。複雜性憩室炎與膿腫、瘻管、腸梗阻或直接穿孔的形成有關。憩室炎傳統上被認為是一種主要的外科疾病並被治療，但即使在最急性的階段，它也已轉變為一種醫療管理的實體內科治療的疾病。[1] [2] [3]
病因學
增加患憩室炎機會的危險因素與憩室病相關的危險因素相同。飲食似乎發揮著重要作用。低纖維、高脂肪和紅肉飲食可能會增加患憩室病和可能的憩室炎的風險。已知肥胖和吸煙會增加憩室炎和憩室出血的可能性。最後，接觸一些藥物，包括非甾體抗炎藥 (NSAID)、類固醇和阿片類藥物，與憩室炎有關。相反，接觸他汀類藥物可能會降低症狀性憩室炎的發生率。儘管人們普遍認為堅果、種子和爆米花與憩室病、憩室炎或憩室出血的風險增加無關。[4] [5]
流行病學
大約 60% 的 60 歲以上人群患有憩室病。約 10% 至 25% 的憩室病患者會發生憩室炎。根據美國最大的全付費住院護理數據庫全國住院患者樣本 (NIS) 的數據顯示，從 1998 年到 2005 年，急性憩室炎住院人數增加了 26%，擇期手術增加了 38%。顯示年輕患者（18 至 44 歲）比老年患者（45 至 74 歲）更有可能入院。這一趨勢可能是由於診斷測試方式的及時診斷和改進。西方國家絕大多數人可能患有左側憩室病，而亞洲人後裔則可能患有右側憩室病。世界各地的，急性憩室炎入院的平均年齡為 63 歲。儘管最初發現這種疾病在男性中更為普遍，但最近的數據顯示，憩室炎在男性和女性中的分佈是相等的。憩室炎更常見於50歲以下的男性和50至70歲的女性。70歲以上患者發生憩室炎的女性較多。[6]
病理生理學
憩室炎是憩室壁微觀和宏觀穿孔的結果。此前，醫生認為糞便堵塞結腸憩室會導致憩室內壓力增加，進而導致穿孔。他們現在推測，腔內壓力增加是由於食物顆粒導致憩室壁侵蝕。這會導致該區域的局灶性炎症和壞死，從而導致穿孔。周圍的腸系膜脂肪很容易含有微穿孔。這可能導致局部膿腫形成、鄰近器官瘻管或腸梗阻。最終，如果不進行快速診斷和治療，直接的腸壁穿孔可能會導致腹膜炎和死亡。[7]
歷史和身體
急性憩室炎的臨床表現根據疾病的嚴重程度而有所不同。患有單純性憩室炎的患者通常會出現左下腹疼痛，這反映了西方國家左側疾病的傾向。然而，亞裔患者主要表現為右側腹痛。疼痛可以是持續性的，也可以是間歇性的。排便習慣的改變，無論是腹瀉（35%）還是便秘（50%），都可能與腹痛有關。患者還可能出現噁心和嘔吐，可能繼發於腸梗阻。膿腫和穿孔患者發燒並不少見。當腸道發炎部分直接接觸膀胱壁時，患者可能會出現排尿困難、尿頻和尿急，這被稱為交感性膀胱炎。
在體檢時，由於腹膜刺激，炎症區域幾乎總是存在觸診壓痛。如果存在膿腫，大約 20% 的患者可能會感覺到腫塊。腸鳴音通常不活躍，但也可以正常。患者可出現腹膜體徵（僵硬、衛衛、反跳痛）並伴有腸壁穿孔。另一方面，發燒幾乎總是存在，但低血壓和休克並不常見。
評估
僅根據病史和體格檢查即可在臨床上診斷急性憩室炎。然而，24% 至 68% 的病例臨床診斷可能不准確。因此，實驗室和放射學檢查在急性憩室炎的準確診斷中起著重要作用。實驗室檢查可能顯示白細胞增多和急性期反應物升高，例如紅細胞沉降率 (ESR) 和 C 反應蛋白 (CRP)。急性憩室炎的首選放射學檢查是腹部和骨盆 CT，最好使用水溶性口服或直腸（如果有明顯噁心和嘔吐）造影劑和靜脈注射造影劑，前提是沒有禁忌症。據報導，CT 掃描的敏感性、特異性和陰性預測值大於 97%。[8]
腹部超聲可準確診斷急性憩室炎，與 CT 相比具有相對敏感性（84% 至 94%）和特異性（80% 至 93%）。然而，超聲（US）結果高度依賴於操作者，儘管數據令人鼓舞、成本較低且易於獲得，但其使用仍受到限制。MRI 是另一種可能的診斷方式。由於成本以及無法直接比較敏感性或特異性，通常首選 CT。腹部 X 光片可能只會顯示非特異性異常，例如腸脹氣；然而，如果患者患有腸梗阻，則可能會出現氣液平面。
由於穿孔風險增加，疑似急性憩室炎應避免進行內窺鏡檢查。建議在症狀消失後大約六到八週進行結腸鏡檢查，以排除惡性腫瘤、炎症性腸病或可能的結腸炎（如果患者最近沒有接受過結腸鏡檢查）。
治療/管理
根據臨床表現，急性憩室炎可以通過門診或住院治療進行治療。根據美國結腸和直腸外科醫生協會的說法，不能耐受口服攝入、過度嘔吐、出現腹膜炎跡象、免疫功能低下或高齡的患者應住院治療。如果不存在這些情況，並且如果可以進行適當的及時隨訪，則可以在門診治療急性憩室炎。據悉，門診管理成功率約為94%至97%。門診護理的標準包括腸道休息、增加液體攝入量和口服抗生素治療（單一或多種藥物療法），涵蓋革蘭氏陰性桿菌和厭氧菌。[8] [3] [9]
憩室炎的住院治療需要靜脈注射抗生素、靜脈輸液和疼痛治療。同樣，抗生素應覆蓋革蘭氏陰性桿菌和厭氧菌，並服用 3 至 5 天，然後改用口服抗生素，療程為 10 至 14 天。對於需要住院的患者，優先選擇腸道休息。通常，應在住院兩到四天內觀察退熱和白細胞增多的改善，否則應懷疑其他診斷或併發症。應考慮立即進行手術評估。
大約 15% 的急性憩室炎患者會出現膿腫，特別是結腸周圍和腸系膜內膿腫。臨床上，如果儘管靜脈注射足夠的抗生素，發燒和白細胞增多仍未消退，則應懷疑膿腫形成。體檢時，腹部壓痛和腫塊壓痛提示可能形成膿腫。小於2厘米至3厘米的膿腫可以用靜脈注射抗生素保守治療。大膿腫應在CT引導下經皮引流。
瘻管形成是急性憩室炎的另一個並發症。據報導，只有不到5%的人會出現瘻管；然而，大約 20% 接受憩室炎手術的患者中發現了這種情況。最常見的瘻管是膀胱瘻管，約佔 65% 的病例。糞尿是結腸膀胱瘺的特有症狀。手術修復瘻管並進行一期吻合術是首選治療方法。結腸陰道瘺、結腸腸瘺、結腸瘺、結腸瘺和結腸皮膚瘺是急性複雜性憩室炎中其他可能出現的瘻管。
結腸腸梗阻引起的部分腸梗阻或假性梗阻也可能發生，可以保守治療。急性憩室炎中完全性腸梗阻很少見。如果發生游離穿孔，應進行手術治療。
預後
憩室炎患者的預後取決於就診年齡、合併症的存在和疾病的嚴重程度。一般來說，年輕人的發病率往往較高，因為他們從不懷疑自己患有這種疾病，而且往往較晚就診。此外，免疫功能低下的患者往往具有較高的發病率和死亡率。[10]
現行療法及其他議題
如前所述，大約 15% 的急性憩室炎患者會出現並發症。百分之二十到百分之五十的患者會出現憩室炎反復發作。多次發作似乎不會直接增加並發症的風險。它可能會增加纖維化的風險，導致狹窄形成和隨後的阻塞。一些患者（約 20%）會因腸易激綜合徵或慢性低度憩室炎而出現慢性腹痛。這些患者可能會被轉診進行選擇性結腸切除術以控制症狀。自 1998 年以來，憩室炎的選擇性手術增加了約 30%。
通過適當的保守治療，無並發症的憩室炎的死亡率可以忽略不計。需要手術的複雜性憩室炎可能導致大約 5% 的患者死亡。腸穿孔引起的腹膜炎會使死亡風險增加至 20%。
Continuing Education Activity
Acute diverticulitis is inflammation of a diverticulum, a sac-like protrusion from the colon wall, due to micro-perforation. Diverticulitis presents in 10% to 25% of patients with diverticulosis. In the past, diverticulitis was treated surgically, however it is now a medically-managed entity, even in its most acute phase. This activity reviews the evaluation and management of diverticulitis and highlights the importance of a well-coordinated interprofessional team in caring for patients with this condition
Objectives:
- Identify risk factors for diverticulitis.
- Explain the clinical evaluation of a patient with diverticulitis.
- Explain how to manage a patient with diverticulitis.
- Outline the role of a collaborative interprofessional team in caring for patients with diverticulitis.
Introduction
Acute diverticulitis is inflammation due to micro-perforation of a diverticulum. The diverticulum is a sac-like protrusion of the colon wall. Diverticulitis can present in about 10% to 25% of patients with diverticulosis. Diverticulitis can be simple or uncomplicated and complicated. Uncomplicated diverticulitis is without any associated complications. Complicated diverticulitis is associated with the formation of abscess, fistula, bowel obstruction, or frank perforation. Diverticulitis has conventionally been known and treated as a primarily surgical illness, but this has transitioned to be a medically managed entity even in its most acute phase.[1][2][3]
Etiology
Risk factors that increase the chances of developing diverticulitis are the same as those related to diverticulosis. Diet appears to play a significant role. Low fiber, high fat, and red meat diets may increase the risk for development of diverticulosis and possible diverticulitis. Obesity and smoking are known to increase the potential for both diverticulitis and diverticular bleeding. Finally, exposure to some drugs including nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, and opiates are associated with diverticulitis. Conversely, exposure to statin drugs may decrease the incidence of symptomatic diverticulitis. Despite a common popular belief, nuts, seeds, and popcorn are not associated with increased risk of diverticulosis, diverticulitis, or diverticular bleeding.[4][5]
Epidemiology
Diverticulosis is present in approximately 60% of people older than 60 years. Diverticulitis occurs in about 10% to 25% of patients with diverticulosis. According to the Nationwide Inpatient Sample (NIS), the largest, all-payer inpatient care database in the United States revealed that there was 26% increase in hospitalizations for acute diverticulitis and a 38% increase in elective operations from 1998 through 2005. It further shows that young patients (18 to 44 years) are more likely to be admitted to the hospital than older patients (45 to 74 years). This trend is likely due to prompt diagnosis and improvement in diagnostic testing modalities. Western nations are overwhelmingly likely to have left-sided diverticulosis, whereas those of Asian descent are likely to have the right-sided disease. Across the world, the mean age for admission for acute diverticulitis is 63 years old. Though the disease was initially noted to be more prevalent in males, more recent data shows that the distribution of diverticulitis is equal in both males and females. Diverticulitis more commonly occurs in men younger than the age of 50 and women 50 to 70 years old. Diverticulitis occurring in patients over the age of 70 are more likely to be female.[6]
Pathophysiology
Diverticulitis is the result of microscopic and macroscopic perforations of the diverticular wall. Previously, practitioners thought that obstruction of colonic diverticulum with fecaliths led to increased pressure within the diverticulum and subsequent perforation. They now theorized that increased luminal pressure is due to food particles that lead to erosion of the diverticular wall. This causes focal inflammation and necrosis of the region, causing perforation. Surrounding mesenteric fat may easily contain micro-perforations. This can result in local abscess formation, fistulization of adjacent organs, or intestinal obstruction. Ultimately, frank bowel wall perforations can lead to peritonitis and death without rapid diagnosis and treatment.[7]
History and Physical
Clinical manifestation of acute diverticulitis varies depending on the severity of the disease. Patients with uncomplicated diverticulitis typically present with left lower quadrant abdominal pain, reflecting that propensity of left-sided disease in Western nations. However, patients of Asian descent present with predominantly right-sided abdominal pain. The pain can be constant or intermittent. Change in bowel habits, either diarrhea (35%) or constipation (50%), can be associated with abdominal pain. Patients may also experience nausea and vomiting, possibly secondary to bowel obstruction. Fever is not uncommon in patients with abscesses and perforation. Dysuria, frequency, and urgency can occur in patients when the inflamed portion of the bowel comes into direct contact with the bladder wall, which is called as sympathetic cystitis.
On physical examination, tenderness to palpation over the area of inflammation is almost always present due to irritation of the peritoneum. A mass may be felt in approximately 20% of patients if an abscess is present. Bowel sounds are usually hypoactive but can be normoactive. Patients can present with peritoneal signs (rigidity, guarding, rebound tenderness) with bowel wall perforation. On the other hand, fever is almost always present, but hypotension and shock are uncommon.
Evaluation
Diagnosis of acute diverticulitis can be made clinically based on history and physical examination alone. However, clinical diagnosis can be inaccurate in 24% to 68% of cases. Hence, laboratory and radiological tests play an important role in the accurate diagnosis of acute diverticulitis. Laboratory tests may show leukocytosis and elevation of acute phase reactants such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The radiological test of choice for acute diverticulitis is CT of the abdomen and pelvis, preferably with water-soluble oral or rectal (if significant nausea and vomiting) contrast and intravenous contrast provided there be no contraindications. The sensitivity, specificity, and negative predictive value of a CT scan have been reported as greater than 97%. Typical findings of acute diverticulitis in CT scans include bowel wall thickening, pericolic fat stranding, pericolic fluid, and small abscesses confined to the colonic wall as well as contrast extravasation, indicating intramural sinus and fistula formation.[8]
Abdominal ultrasound can accurately diagnose acute diverticulitis, with comparative sensitivity (84% to 94%) and specificity (80% to 93%) as of CT. However, ultrasound (US) results are highly operator dependent, and use is limited despite encouraging data, lower cost, and easy availability. MRI is another possible diagnostic modality. Due to cost and no direct comparison of sensitivity or specificity, CT is usually preferred. Radiographs of the abdomen will probably only show nonspecific abnormalities such as bowel gas; however, if the patient has an intestinal obstruction, air-fluid levels can be present.
Endoscopy should be avoided in suspected acute diverticulitis due to an increased risk of perforation. It is recommended that a colonoscopy is performed approximately six to eight weeks after symptoms have resolved to rule out malignancy, inflammatory bowel disease, or possibly colitis if the patient has not had a recent colonoscopy.
Treatment / Management
Upon clinical presentation, acute diverticulitis can be managed with either outpatient or inpatient care. According to American Society of Colon and Rectal Surgeons, a patient who cannot tolerate oral intake, is excessively vomiting, shows signs of peritonitis, is immunocompromised, or at an advanced age should be hospitalized. In the absence of these conditions, and if appropriate prompt follow-up can be established, acute diverticulitis can be managed on an outpatient basis. It is reported that success rate of outpatient management is about 94% to 97%. The standard of outpatient care includes bowel rest, increase fluid intake, and oral antibiotic therapy (single or multiple drug regimen) that covers gram-negative rods and anaerobic bacteria. The most common regimen used in the United States consists of quinolones (ciprofloxacin) or sulfa drugs (trimethoprim/sulfamethoxazole) in combination with metronidazole (or clindamycin, if the patient is intolerant to metronidazole) or single agent amoxicillin-clavulanate for 7 to 10 days.[8][3][9]
Inpatient management of diverticulitis requires intravenous antibiotics, intravenous fluids, and pain management. Again, antibiotics should cover gram-negative rods and anaerobes and be given for three to 5 days before switching to oral antibiotics for a ten to 14-day course. Bowel rest is preferred in patients requiring inpatient admission. Typically, defervescence and improvement in leukocytosis should be observed for two to four days of hospitalization, if not an alternative diagnosis or complications should be suspected. Prompt surgical evaluation should be considered.
About 15% patients with acute diverticulitis develop an abscess, specifically pericolonic and intra-mesenteric. Clinically, abscess formation should be suspected if fever and leukocytosis do not subside despite adequate intravenous (IV) antibiotics. On physical exam, a tender abdomen and tender mass suggest possible abscess formation. Abscesses that are less than 2 cm to 3 cm can be treated conservatively with IV antibiotics. Large abscesses should be drained percutaneously with CT guidance.
Fistula formation is another complication of acute diverticulitis. It is reported that less than 5% develops fistula; however, it has been found in about 20% of patients who undergo surgery for diverticulitis. The most common fistula is colovesicular fistula which occurs in about 65% of cases. Fecaluria is pathognomonic for colovesicular fistula. Surgical repair of the fistula with primary anastomosis is the treatment of choice. Colovaginal, coloenteric, colouterine, colourethral, and colocutaneous are other possible fistulae seen in acute complicated diverticulitis.
Partial bowel obstruction or pseudo-obstruction due to colonic ileus can occur as well, which can be managed conservatively. Complete bowel obstruction is rare in acute diverticulitis. Free perforation, if it occurs, should be managed surgically.
Differential Diagnosis
- Cholangitis
- Cholecystitis
- Chronic mesenteric ischemia
- Constipation
- Enterovesical fistula
- Gynecological pain
- Inflammatory bowel disease
- Intestinal perforation
- Irritable bowel syndrome (IBS)
- Large-bowel obstruction
Prognosis
The prognosis of patients with diverticulitis depends on age at presentation, the presence of comorbidity and severity of the disease. In general, younger people tend to have a higher morbidity as they never suspect they have the disorder and often present late. In addition, patients who are immunocompromised tend to have high morbidity and mortality.[10]
Complications
- Pelvic abscess
- Intestinal perforation
- Bowel fistula
- Peritonitis
- Bowel obstruction
- Sepsis
- Bleeding per rectum
Postoperative and Rehabilitation Care
After recovering from diverticulitis, the patient must be examined to rule out a malignancy. Options for investigation of the colon include colonoscopy, CT scan or a barium enema.
The patient should start a high-fiber diet, drink ample water, maintain a healthy weight and exercise.
Pearls and Other Issues
As previously stated, approximately 15% of patients with acute diverticulitis develop complications. Twenty percent to 50% of patients develop recurrent episodes of diverticulitis. Having multiple episodes does not appear to increase the risk for complications directly. It may increase the risk of fibrosis, leading to stricture formation and subsequent obstruction. Some patients, approximately 20%, will experience chronic abdominal pain due to either irritable bowel syndrome or chronic low-grade diverticulitis. These patients may be referred for elective colectomy for symptom control. Elective operations for diverticulitis have increased by approximately 30% since 1998.
The mortality rate in uncomplicated diverticulitis is negligible with appropriate conservative therapy. Complicated diverticulitis requiring surgery may lead to death in approximately 5% of patients. Perforation of the bowel with resulting peritonitis increases the risk of death to 20%.
Enhancing Healthcare Team Outcomes
Acute diverticulitis has enormous morbidity and while there are no universal guidelines, expert opinion recommends an interprofessional approach for diagnosis and management. The disorder needs to be staged radiologically. In addition, the patient needs a dietary consult regarding a high-fiber diet. Nurses need to assist in educating the patient on following dietary restrictions. An infectious disease consultant and a gastroenterologist need to determine the duration of antibiotic therapy and a general surgeon is necessary to develop a protocol for management of any pelvic abscess. Finally, a general or colorectal surgery should determine the proximal levels of colon resection but the amount of clear proximal margin needed remains unknown. Because the risk of colon cancer in patients with acute diverticulitis is slightly increased, a screening program has to be established.[11][12] [13] (Level III)
Outcomes
Many cases studies reveal that the majority of patients treated for acute diverticulitis do not have a recurrence after initial medical treatment. However, in patients with recurrence, surgical excision of the diseased bowel is recommended, especially in patients over the age of 50. (Level V) Finally, the decision to perform laparoscopic or open surgery for managing acute diverticulitis remains debatable. One study showed no difference in postoperative morbidity between the two. [2][14](Level III) Randomized clinical studies are needed to determine which surgery and what type of surgery is ideal for patients with acute diverticulitis.
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