Diverticula

Protrusions of the walls of individual hollow organs; pathological protrusions of the walls of individual hollow organs;

Definition

A diverticulum is a saccular protrusion of the entire tissue layers or individual layers of the lining of internal cavities (Neumann 2008 / MSD Sharp and Dohme 2007). If numerous but asymptomatic diverticula are found, the condition is referred to as diverticulosis. The size of colonic diverticula, for example, ranges from 3 mm - 3 cm; so-called giant diverticula can grow up to 15 cm in size. If the diverticula cause symptoms, it is referred to as "diverticular disease" (Mader 2018 / MSD Sharp and Dohme 2007).

A distinction is made between true diverticula and pseudodiverticula:

• True diverticula, also known as "traction diverticula" (Block 2005):

These represent protrusions of all layers of the intestinal wall

• Pseudodiverticula also called "false diverticula" or pulsion diverticula" (Block 2005 /MSD Sharp and Dohme 2007):

These are protrusions of the mucosa (and submucosa [Block 2005]) in the area of muscle gaps (Herold 2022).

Diverticula in the esophagus, stomach, and small intestine are rare, but colonic diverticula are common (Frieling 2021), the latter being the most common disease of the colon worldwide. The global incidence ranges from 5 - 37%. The incidence of diverticula increases with age (Raguse 2001). In < 40-year-olds, diverticula are usually found only rarely (MSD Sharp and Dohme 2007), while up to 65% are affected in > 85-year-olds (Mader 2018).

Diverticula in the intestine probably develop as a result of a lifelong low-fiber diet. However, the mechanism of development is not completely certain (MSD Sharp and Dohme 2007).

Colonic diverticula are thought to develop as a result of increased intraluminal pressure. This results in an outpouching of the mucosa, which bulges into the lumen at the weakest points in the muscle layer (MSD Sharp and Dohme 2007).

Diverticula can occur in the:

• Esophagus (so-called true diverticula [MSD Sharp and Dohme 2007)]); these may be localized:
  • cervical as so-called Zenker diverticula (these are the most frequent esophageal diverticula with up to 70 %)
  • thoracic (occurring in about 22 % of esophageal diverticula)
  • epiphrenal (occurring in about 8 % of esophageal diverticula)

(Block 2005)

• Stomach
• duodenum (here often in the area of the papilla)
• Ileum as Meckel's diverticula (these are true diverticula [MSD Sharp and Dohme 2007)])
• Colon (predominantly in the sigmoid; these are pseudodiverticula [MSD Sharp and Dohme 2007)])

(Herold 2022)

Diverticula occur in the sigmoid in approximately 95% of Europeans (Mader 2018) and then show ascension. In the Asian region, the Anterior Orient, and Malta, an onset is often seen in the right colon with descension.

Most diverticula in the intestine are in the sigmoid because of increased pressure (Raguse 2001).

Very rarely, diverticula are found in the lacrimal sac (Enright 2019), coronary sinus (Razeghian- Jahromi 2020), ureter (McLoughlin 2013), etc.

The clinical picture differs depending on the localization:

• Zenker's diverticulum:
  • Dysphagia
  • retention symptoms (Feußner 2011)
  • Foetor ex ore (Krombach 2015)
• Esophageal diverticulum:
  • Dysphagia
  • Regurgitations
  • Aspiration event (Lakhani 2020)
• Coronary sinus:
  • Cardiac arrhythmias (Razeghian- Jahromi 2020)
• Small bowel diverticulum:
  • Gastrointestinal bleeding (Zhao 2018).
• Colonic diverticulum:
  • The majority of patients remain asymptomatic throughout their lives. With increasing duration of history, diverticular disease may develop with:
    • Painful inflammation in 10 - 40% (occur especially in younger and immunocompromised patients).
    • bleeding in 4.5 - 50 %, with mass hemorrhage in 2 - 9 % with volume losses up to 2,000 ml within 24 h (bleeding is often found with increasing age of patients (Raguse 2001)
    • Diarrhea
    • Meteorism
    • Flatulence (Mader 2018)

• esophagus:

These diverticula can usually be diagnosed by a pap-swallow examination in 2 planes (Krombach 2015).

• Colon:

Intestinal diverticula can be diagnosed by colonoscopy or KE- enema.

In case of rectal bleeding caused by diverticula, an elective colonoscopy should be performed. In case of a more severe bleeding, a rapid bowel cleansing with 5 - 10 l polyethylene glycol solution in 3 - 4 h by stomach tube is recommended. If the source of bleeding cannot be identified by colonoscopy, it may be possible to localize it by angiography (MSD Sharp and Dohme 2007).

Diagnosis of diverticular disease s. d.

Diverticula in the colon can become inflamed and cause so-called "diverticular disease" (Herold 2022). These inflammatory changes are more frequently found in the left colon (Raguse 2001).

They can also lead to bleeding as diverticulosis in the colon (MSD Sharp and Dohme 2007). These are found more frequently in the left colon (Raguse 2001).

The therapy of diverticula depends on the location and the symptoms:

• Pharyngo-oesophageal diverticula: These were treated surgically until 20 - 30 years ago, but are now increasingly treated endoscopically by gastroenterologists (Gutschow 2017).
  • Zenker's diverticulum: In this case, an indication for surgical treatment is given with the diagnosis in order to eliminate the above-mentioned symptoms and to avoid recurrences (Feußner 2011).
  • Thoracic diverticula: A therapy is normally not necessary (Block 2005).
  • Epiphrenic diverticula: If it is a large, symptomatic diverticulum, it should be surgically removed (Block 2005).
• Colonic diverticulum:

Patients with diverticulosis are advised to eat a high-fiber diet, avoiding seeds, etc., because of the risk of entrapment in the diverticulum. Surgical measures are not indicated in uncomplicated cases. Giant diverticula, on the other hand, should always be surgically removed (MSD Sharp and Dohme 2007).

• Hemorrhage:

Diverticular bleeding resolves spontaneously in up to 75% of patients. Otherwise, intra-arterial injections with vasopressin can be terminated. Angiographic embolization also stops bleeding but can lead to bowel infarction in up to 20% of patients and is therefore not recommended (MSD Sharp and Dohme 2007).

• Diverticulitis: s. d.

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