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Divertikelsjukdom

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Definition:
Divertikulos är ett tillstånd med divertiklar i form av kolonmukosa som hernierar genom muscularis, främst i sigmoideum men också i kolon descendens och ibland i högerkolon. Divertikelsjukdom betecknar divertikulos med symtom.
Förekomst:
Prevalensen divertikulos var 27 % för alla åldrar och 60–80 % >60 års ålder i en stor nederländsk undersökning. Divertikulit utvecklas hos cirka 1–4 % av personer med divertiklar i kolon.
Symtom:
Symtom kan vara ändrade avföringsvanor, vänstersidiga koliksmärtor som lindras vid defekation och gasbildning. Divertikulos är asymtomatiskt hos 80–90 %.
Kliniska fynd:
Oftast inga kliniska fynd. Vid divertikulit föreligger feber och palpationsömhet företrädesvis i nedre vänsterkvadranten. Divertiklar kan ibland leda till tarmblödning.
Diagnostik:
Vid akut divertikulit ses typiska röntgenfynd på DT buk i kombination med stegrade inflammationsparametrar. Vid genomgången förstagångsdivertikulit bör patienten genomgå koloskopi eller DT kolon efter 4–6 veckor för att utesluta koloncancer.
Behandling:
Divertikelsjukdom kräver oftast ingen annan behandling än information. Vid okomplicerad divertikulit rekommenderas tarmvila (alternativt skonkost/flytande kost om patienten har återgått till hemmet). Vid komplicerad divertikulit ges även antibiotika. I vissa fall krävs kirurgi.
  1. Salzman H, Lillie D. Diverticular disease: Diagnosis and treatment. Am Fam Physician 2005; 72: 1229-34. PubMed  
  2. Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004; 363: 631-9. PubMed  
  3. Young-Fadok TM, Roberts PL, Spencer MP, Wolff BG. Colonic diverticular disease. Curr Probl Surg 2000; 37: 457-514. PubMed  
  4. Janes SEJ, Meagher A, Frizelle FA. Management of diverticulitis. BMJ 2006; 332: 271-5. PubMed  
  5. Jacobs DO. Diverticulitis. N Engl J Med 2007; 357: 2057-66. PubMed  
  6. Loffeld RJ, Van Der Putten AB. Diverticular disease of the colon and concomitant abnormalities in patients undergoing endoscopic evaluation of the large bowel. Colorectal Dis 2002; 4: 189-92. PubMed  
  7. Peery AF.Recent Advances in Diverticular Disease. Curr Gastroenterol Rep. 2016 Jul;18(7):37. PMID: 27241190. PubMed  
  8. Mäkelä J, Kiviniemi H, Laitinen S. Prevalence of perforated sigmoid diverticulitis is increasing. Dis Colon Rectum 2002; 45: 955-61. PubMed  
  9. Kang JY, Hoare J, Tinto A, Subramanian S, Ellis C, Majeed A, Melville D, Maxwell JD. Diverticular disease of the colon--on the rise: a study of hospital admissions in England between 1989/1990 and 1999/2000. Aliment Pharmacol Ther. 2003 May 1;17(9):1189-95. PubMed PMID: 12752356 PubMed  
  10. Simpson J, Scholefield JH, Spiller RC. Pathogenesis of colonic diverticula. Br J Surg 2002; 89: 546-54. PubMed  
  11. Granlund J, Svensson T, Olén O, Hjern F, Pedersen NL, Magnusson PK, Schmidt PT. The genetic influence on diverticular disease--a twin study. Aliment Pharmacol Ther. 2012 May;35(9):1103-7. doi: 10.1111/j.1365-2036.2012.05069.x. Epub 2012 Mar 20. PubMed PMID: 22432696 PubMed  
  12. Bode MK, Karttunen TJ, Makela J, Risteli L, Risteli J. Type I and III collagens in human colon cancer and diverticulosis. Scand J Gastroenterol 2000; 35: 747-52. PubMed  
  13. Camilleri M, Sandler RS, Peery AF. Etiopathogenetic Mechanisms in Diverticular Disease of the Colon. Cell Mol Gastroenterol Hepatol. 2020;9(1):15-32. doi: 10.1016/j.jcmgh.2019.07.007. Epub 2019 Jul 25. PMID: 31351939 PubMed  
  14. Meyers MA, Alonso DR, Gray GF, Baer JW. Pathogenesis of bleeding colonic diverticulosis. Gastroenterology. 1976 Oct;71(4):577-83. PMID: 1085269 PubMed  
  15. Wong SK, Ho YH, Leong AP, Seow-Choen F. Clinical behavior of complicated right-sided and left-sided diverticulosis. Dis Colon Rectum 1997; 40: 344-8. PubMed  
  16. Wilkins T, Baird C, Pearson AN, Schade RR. Diverticular bleeding. Am Fam Physician. 2009 Nov 1;80(9):977-83. PMID: 19873964 PubMed  
  17. Strate LL, Orav EJ, Syngal S. Early predictors of severity in acute lower intestinal tract bleeding. Arch Intern Med 2003; 163: 838-43. PubMed  
  18. Shah SD, Cifu AS. Management of Acute Diverticulitis. JAMA. 2017 Jul 18;318(3):291-292. doi: 10.1001/jama.2017.6373. PMID: 28719679 PubMed  
  19. Halligan S, Saunders B. Imaging diverticular disease. Best Pract Res Clin Gastroenterol 2002; 16: 595-610. PubMed  
  20. van Dijk ST, Daniels L, de Korte N, et al. Quality of Life and Persistent Symptoms After Uncomplicated Acute Diverticulitis. Dis Colon Rectum. 2019 May;62(5):608-614. pmid:30807455 PubMed  
  21. Reinus JF, Brandt LJ. Vascular ectasias and diverticulosis. Common causes of lower intestinal bleeding. Gastroenterol Clin North Am 1994; 23: 1-20. PubMed  
  22. Fine KD, Nelson AC, Ellington RT, Mossburg A. Comparison of the color of fecal blood with the anatomical location of gastrointestinal bleeding lesions: potential misdiagnosis using only flexible sigmoidoscopy for bright red blood per rectum. Am J Gastroenterol 1999; 94: 3202-10. PubMed  
  23. Altman D, Forsgren C, Hjern F, Lundholm C, Cnattingius S, Johansson AL. Influence of hysterectomy on fistula formation in women with diverticulitis. Br J Surg. 2010 Feb;97(2):251-7. doi: 10.1002/bjs.6855. PubMed PMID: 20035535 PubMed  
  24. Hjern F, Goldberg SM, Johansson C, Parker SC, Mellgren A. Management of diverticular fistulae to the female genital tract. Colorectal Dis. 2007 Jun;9(5):438-42. PubMed PMID: 17504341 PubMed  
  25. Thaha MA, Carrington E. Diverticular disease. BMJ BestPractice, last updated 15 Oct 2019. bestpractice.bmj.com  
  26. Thorson CM, PazRuiz PS et al. The perforated duodenal diverticulum. Arch Surg 2012; 47 (1): 81-8. pmid: 22250120 PubMed  
  27. Divertikulit. Nationellt kliniskt kunskapsstöd, NKK (hämtad 2021-12-20) nationelltklinisktkunskapsstod.se  
  28. Janes SEJ, Meagher A, Frizelle FA. Elective surgery after acute diverticulitis. Br J Surg 2005; 92: 133-42. PubMed  
  29. de Korte N, Unlü C et al. Use of antibiotics in uncomplicated diverticulitis.. Br J Surg 2011; 98(6): 761-767. PubMed  
  30. Chabok A, Påhlman L et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012; 99(4): 532-539. PubMed  
  31. Ünlü C, Daniels L et al. A systematic review of high-fibre dietary therapy in diverticular disease. Int J Colorectal Dis 2012; 27(4): 419-27. pmid:21922199 PubMed  
  32. Hart AR, Kennedy HJ, Stebbings WS, Day NE. How frequently do large bowel diverticula perforate? An incidence and cross-sectional study. Eur J Gastroenterol Hepatol 2000; 12: 661-5. PubMed  
  33. Hjern F, Mahmood MW, Abraham-Nordling M, Wolk A, Håkansson N. Cohort study of corticosteroid use and risk of hospital admission for diverticular disease. Br J Surg. 2015 Jan;102(1):119-24. doi: 10.1002/bjs.9686. Epub 2014 Nov 12. PubMed PMID: 25389076 PubMed  
  34. van Dijk ST, Daniels L, Unlu C, et al. Long-Term Effects of Omitting Antibiotics in Uncomplicated Acute Diverticulitis. Am J Gastroenterol 2018. pmid:29700480 www.ncbi.nlm.nih.gov  
  35. Reisman Y, Ziv Y, Kravrovitc D, Negri M, Wolloch Y, Halevy A. Diverticulitis: the effect of age and location on the course of disease. Int J Colorectal Dis 1999; 14: 250-4. PubMed  
  36. Angenete E, Thornell A, Burcharth J et al. Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent Peritonitis: The First Results From the Randomized Controlled Trial DILALA. Ann Surg. 2016 Jan;263(1):117-22. PMID: 25489672 PubMed  
  37. Angenete E, Bock D, Rosenberg J, Haglind E. Laparoscopic lavage is superior to colon resection for perforated purulent diverticulitis-a meta-analysis. Int J Colorectal Dis. 2017 Feb;32(2):163-169. doi: 10.1007/s00384-016-2636-0. Epub 2016 Aug 27. PMID: 27567926 PubMed  
  38. Bissolati M, Orsenigo E, Staudacher C, et al. Role of minimally invasive surgery in the treatment of diverticular disease: an evidence-based analysis. Updates Surg. 2015 Dec;67(4):353-65. pmid: 26449963 PubMed  
  39. Wong WD, Wexner SD, Lowry A, et al. Practice parameters for the treatment of sigmoid diverticulitis: supporting documentation. Dis Colon Rectum 2000; 43: 290-97. PubMed  
  40. Schultz JK, Yaqub S, Wallon C, et al. Laparoscopic lavage vs primary resection for acute perforated diverticulitis. The SCANDIV randomized clinical trial. JAMA 2015; 314: 1364-75. doi:10.1001/jama.2015.12076 DOI  
  41. Zuckerman GR, Prakash C. Acute lower intestinal bleeding: part II--etiology, therapy, and outcomes. Gastrointest Endosc 1999; 49: 228-38. PubMed  
  42. Davila RE, Rajan E, Adler DG, et al., for the Standards of Practice Committee. ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. Gastrointest Endosc 2005; 62: 656-60. PubMed  
  43. Chen CY, Wu CC, Jao SW, Pai L, Hsiao CW. Colonic diverticular bleeding with comorbid diseases may need elective colectomy. J Gastrointest Surg 2009; 13: 516-20 PubMed  
  44. Haglund U, Hellberg R, Johnsen C, Hulten L. Complicated diverticular disease of the sigmoid colon. An analysis of short and long term outcome in 392 patients. Ann Chir Gynaecol 1979; 68: 41-6. PubMed  
  45. Goh H, Bourne R. Non-steroidal anti-inflammatory drugs and perforated diverticular disease: a case-control study. Ann R Coll Surg Engl 2002; 84: 93-6. PubMed  
  46. Salem TA, Molloy RG, O'Dwyer PJ. Prospective, five-year follow-up study of patients with symptomatic uncomplicated diverticular disease. Dis Colon Rectum 2007; 50: 1460-4. PubMed  
  47. Munson KD, Hensien MA, Jacob LN, Robinson AM, Liston WA. Diverticulitis. A comprehensive follow-up. Dis Colon Rectum 1996; 39: 318-22. PubMed  
  48. Sarin S, Boulos PB. Long-term outcome of patients presenting with acute complications of diverticular disease. Ann R Coll Surg Engl 1994; 76: 117-20. PubMed  
  49. Simpson J, Spiller R. Colonic diverticular disease. Clinical Evidence 2001; 6: 336-43. PubMed  
  50. Chabok A, Thorisson A, Nikberg M, Schultz JK, Sallinen V. Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis. Scand J Surg. 2021 Jun;110(2):180-186. doi: 10.1177/14574969211011032. Epub 2021 May 3. PMID: 33934672 PubMed  
  51. Divertikulit. Akut kirurgi, behandlingshandbok 2022. Region Stockholm kunskapsstodforvardgivare.se  
  52. Standardiserat vårdförlopp, tjock- och ändtarmscancer, kortversion för primärvården (hämtad 2022-04-05) cancercentrum.se  
  • Anna Nager, docent och specialist i allmänmedicin, Karolinska institutet