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Wednesday, 4 December 2013

Diverticulitis Treatments In conventional medicine perspective

Diverticulitis is defined as a condition of inflammation of the small, bulging sacs or pouches of the inner lining of the intestine that bulge outward through weak spots as a result of small pieces of stool (feces) trapped in these pouches. In most cases, the disease is found in the large intestine (colon). According to the statistic, approximately, About 10 percent of Americans older than 40 have diverticulosis.
In the examination of the data fom January 2004 to June 2005 of 796 consecutive patients referred for total colonoscopy to 17 physicians included age, gender, presence and localization of diverticula. This population was compared with a cohort of 133 consecutive patients who were admitted for colonic diverticular bleeding, showed that the prevalence of colonic diverticula increased from less than 10% in adults under 40 to about 75% in those over 75 years. Of these patients, nearly one third presented with right-sided involvement(1).
VI. Treatments
A.1. In conventional medicine perspective
According to the study by American Family Pgysician, hospitalization is recommended if patients show signs of significant inflammation, are unable to take oral fluids, are older than 85 years, or have significant comorbid conditions(52).
A.1.1. Non surgical treatment
1. Antibiotics
Also according to tthe study byUnit, Department of Surgery, Hospital Universitario del Mar, All patients diagnosed with uncomplicated diverticulitis based on abdominal computed tomography findings from June 2003 to December 2008 were considered for outpatient treatment. Treatment consisted of oral antibiotics for 7 days (amoxicillin-clavulanic or ciprofloxacin plus metronidazole in patients with penicillin allergy). Patients were seen again at between 4 and 7 days after starting treatment to confirm symptom improvement(53). Side effects are not limit to rash, diarrhea, abdominal pain, nausea/vomiting, drug fever, hypersensitivity (allergic) reactions, etc.
2. Anti-inflammatory medicine
Mesalazine is an anti-inflammatory drug used to treat inflammatory bowel disease. According to ths study by the University of Parma, Inflammation in such diseases seems to be generated by a heightened production of proinflammatory cytokines, reduced anti-inflammatory cytokines, and enhanced intramucosal synthesis of nitric oxide. The mechanisms of action of mesalazine are not yet well understood. It is an anti-inflammatory drug that inhibits factors of the inflammatory cascade (such as cyclooxygenase) and free radicals, and has an intrinsic antioxidant effect. Some recent studies confirm the efficacy of mesalazine in diverticular disease both in relief of symptoms in symptomatic uncomplicated forms and in prevention of recurrence of symptoms and main complications(54). Side effects are not limit to Diarrhea, Nausea, Cramping, Flatulence, etc.
A.1.2. Surgical treatments
According to the WGO 2007 guidelines, 15-30% of patients admitted for management of diverticulitis will need surgery during their admission, with an 18% surgical mortality rate(55).
1. Laparoscopic lavage
Traditionally the management of acute diverticulitis complicated by perforation has been the Hartmann’s procedure, which may be associated with significant morbidity and mortality and the unpleasantness of a colostomy(56). According to the study by John Flynn Gold Coast Hospital, Gold Coast, Queensland, Australia, In the data of Treatment with laparoscopic lavage was performed in only 38 patients in ten hospitals, found that lavage was successful in controlling sepsis in 31 of the 38 included patients, with 32 per cent morbidity (10 of 31 patients) and fast recovery. Overall, 17 of 38 patients developed complications, of whom two had a missed overt sigmoid perforation(57). Other study suggested that the Hartman modification consists of the creation of a distal mucus fistula rather than suturing the rectum closed. To facilitate the creation of a distal mucus fistula, it is suggested that less sigmoid colon be resected at the time of the initial operation. The colon can be assessed for residual diverticular disease later and more resected at the later closure operation if required(58).
2. Colostomy
Colostomy is a surgical procedure to bring one end of the large intestine out through the abdominal wall. There is a report by the University of Pittsburgh Medical Centre of a 62-year-old Caucasian woman with a history of sigmoid diverticulitis presented to our facility with a three-week history of abdominal pain, fevers, chills, loss of appetite and fatigue. Her laboratory test results showed leukocytosis and elevated alkaline phosphatase. A computed tomography scan revealed portal vein thrombosis and a sigmoid diverticulitis with an abscess. Our patient was given pipercillin-tozabactam followed by sigmoid colectomy and loop transverse colostomy(59).
3. Ileostomy
Ileostomy is surgical procedure to bring the end or loop of small intestine (the ileum) out onto the surface of the skin. According to the study by the Surgical Specialists of Spokane, the use of diverting loop ileostomy in patients undergoing colon and rectal surgery with high-risk anastomoses is beneficial. Their selected use has resulted in a 1% anastomotic loss rate with an acceptably low rate of complications related to the ileostomy(60).
4. Other surgical procedure such as the classic 3-stage surgical approach is no longer mention, as a result of high associated morbidity and mortality.
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Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/23350931
(52) http://www.aafp.org/afp/2005/1001/p1229.html
(53) http://www.ncbi.nlm.nih.gov/pubmed/19906059
(54) http://www.ncbi.nlm.nih.gov/pubmed/16885700
(55) http://www.worldgastroenterology.org/diverticular-disease.html
(56) http://www.ncbi.nlm.nih.gov/pubmed/17054542
(57) http://www.ncbi.nlm.nih.gov/pubmed/23404411
(58) http://www.ncbi.nlm.nih.gov/pubmed/7350709
(59) http://www.ncbi.nlm.nih.gov/pubmed/21985694
(60) http://www.ncbi.nlm.nih.gov/pubmed/17434360