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If small and asymptomatic, no treatment is necessary. Larger, symptomatic cases of Zenker's diverticulum have been traditionally treated by neck surgery to resect the diverticulum and incise the cricopharyngeus muscle. However, in recent times non-surgical endoscopic techniques have gained more importance (as they allow for much faster recovery), and the currently preferred treatment is endoscopic stapling (i.e. diverticulotomy with staples ). This may be performed through a diverticuloscope. Other methods include fibreoptic diverticular repair.
Other non-surgical treatment modalities also exist, such as endoscopic laser, which recent evidence suggests is less effective than stapling.
A high-fiber diet and fiber supplements are advisable to prevent constipation. The American Dietetic Association recommends 20–35 grams each day. Wheat bran has been shown to reduce intra colonic pressure.
The US National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says foods such as nuts, popcorn hulls, sunflower seeds, pumpkin seeds, caraway seeds, and sesame seeds have traditionally been labeled as problem foods for people with this condition; however, no scientific data exists to prove this hypothesis. The seeds in tomatoes, zucchini, cucumbers, strawberries, raspberries, and poppy seeds, are not considered harmful by the NIDDK.
One study found that nuts and popcorn do not contribute positively or negatively to patients with diverticulosis or diverticular complications.
Many people with diverticulosis have minimal to no symptoms, and do not require any specific treatment. Colonic stimulants should be avoided. Treatments, like some colon cleansers, that cause hard stools, constipation, and straining, are not recommended.
Treatment is surgical, potentially with a laparoscopic resection. In patients with bleeding, strangulation of bowel, bowel perforation or bowel obstruction, treatment involves surgical resection of both the Meckel's diverticulum itself along with the adjacent bowel segment, and this procedure is called a "small bowel resection". In patients without any of the aforementioned complications, treatment involves surgical resection of the Meckel's diverticulum only, and this procedure is called a simple diverticulectomy.
With regards to asymptomatic Meckel's diverticulum, some recommend that a search for Meckel's diverticulum should be conducted in every case of appendectomy/laparotomy done for acute abdomen, and if found, Meckel's diverticulectomy or resection should be performed to avoid secondary complications arising from it.
A Killian–Jamieson diverticulum is an outpouching of the esophagus just below the upper esophageal sphincter.
The physicians that first discovered the diverticulum were Gustav Killian and James Jamieson. Diverticula are seldom larger than 1.5 cm, and are less frequent than the similar Zenker's diverticula. As opposed to a Zenker's, which is typically a posterior and inferior outpouching from the esophagus, a Killian–Jamieson diverticulum is typically an anterolateral outpouching at the level of the C5-C6 vertebral bodies, due to a congenital weakness in the cervical esophagus just below the cricopharyngeal muscle. It is usually smaller in size than a Zenker's diverticulum, and typically asymptomatic. Although congenital, it is more commonly seen in elderly patients.
A diverticulum (plural: "diverticula") is the medical or biological term for an outpouching of a hollow (or a fluid-filled) structure in the body. Depending upon which layers of the structure are involved, they are described as being either true or false.
In medicine, the term usually implies the structure is not normally present. However, in the embryonic stage, some normal structures begin development as a diverticulum arising from another structure.
Meckel's diverticulum occurs in about 2% of the population. Prevalence in males is 3–5 times higher than in females. Only 2% of cases are symptomatic, which usually presents among children at the age of 2.
Most cases of Meckel's diverticulum are diagnosed when complications manifest or incidentally in unrelated conditions such as laparotomy, laparoscopy or contrast study of the small intestine. Classic presentation in adults includes intestinal obstruction and inflammation of the diverticulum (diverticulitis). Painless rectal bleeding most commonly occurs in toddlers.
Inflammation in the ileal diverticulum has symptoms that mimic appendicitis, therefore its diagnosis is of clinical importance. Detailed knowledge of the pathophysiological properties is essential in dealing with the life-threatening complications of Meckel's diverticulum.
Left untreated, urethral diverticulum can cause significant morbidity (sickness).
During surgery, there is a risk for complications due to the highly vascular nature of the tissue. The urethral sphincters and its smooth muscle, as well as the neck of the bladder, can be injured regardless of the surgical approach. Other complications from surgery can include urinary incontinence, stress incontinence, a urethrovaginal fistula, or recurrent diverticula. Horseshoe-shaped diverticula and diverticula that completely surround the urethra are both associated with worse outcomes, as are those located close to the bladder, and large (over 3–4 cm) diverticula.
Distal or sigmoid, fecalomas can often be disimpacted digitally or by a catheter which carries a flow of disimpaction fluid (water or other solvent or lubricant). Surgical intervention in the form of sigmoid colectomy or proctocolectomy and ileostomy may be required only when all conservative measures of evacuation fail.
People may be placed on a low fibre diet. It was previously thought that a low-fibre diet gives the colon adequate time to heal. Evidence tends to run counter to this with a 2011 review finding no evidence for the superiority of low fibre diets in treating diverticular disease and that a high-fibre diet may prevent diverticular disease. A systematic review published in 2012 found no high quality studies, but found that some studies and guidelines favour a high-fibre diet for the treatment of symptomatic disease. While it has been suggested that probiotics may be useful for treatment, the evidence currently neither supports nor refutes this claim.
Treatment for sigmoid volvulus may include sigmoidoscopy. If the mucosa of the sigmoid looks normal and pink, place a rectal tube for decompression, correct any fluid, electrolyte, cardiac, renal or pulmonary abnormalities and then take the person to the operating room for repair. If surgery is not performed, there is a high rate of recurrence.
For people with signs of sepsis or an abdominal catastrophe, immediate surgery and resection is advised.
The primary treatment for urethral diverticulum is surgical. The surgery is conducted transvaginally, usually when there is no acute inflammation to better aid dissection of the delicate tissues.
Choledochal cysts are treated by surgical excision of the cyst with the formation of a roux-en-Y anastomosis hepaticojujenostomy/ choledochojujenostomy to the biliary duct.
Future complications include cholangitis and a 2% risk of malignancy, which may develop in any part of the biliary tree. A recent article published in Journal of Surgery suggested that choledochal cysts could also be treated with single-incision laparoscopic hepaticojejunostomy with comparable results and less scarring. In cases of saccular type of cyst, excision and placement of T-shaped tube is done.
Currently, there is no accepted indication for fetal intervention in the management of prenatally suspected choledochal cysts.
A Zenker's diverticulum, also pharyngoesophageal diverticulum, also pharyngeal pouch, also hypopharyngeal diverticulum, is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the esophagus). It is a pseudo diverticulum (not involving all layers of the esophageal wall).
It was named in 1877 by German pathologist Friedrich Albert von Zenker.
Most cases of simple, uncomplicated diverticulitis respond to conservative therapy with bowel rest.
Possible treatments include:
- In stable cases, use of laxatives and bulking agents, as well as modifications in diet and stool habits are effective.
- Corticosteroids and other anti-inflammatory medication is used in toxic megacolon.
- Antibiotics are used for bacterial infections such as oral vancomycin for "Clostridium difficile"
- Disimpaction of feces and decompression using anorectal and nasogastric tubes.
- When megacolon worsens and the conservative measures fail to restore transit, surgery may be necessary.
- Bethanechol can also be used to treat megacolon by means of its direct cholinergic action and its stimulation of muscarinic receptors which bring about a parasympathetic like effect.
There are several surgical approaches to treat megacolon, such as a colectomy (removal of the entire colon) with ileorectal anastomosis (ligation of the remaining ileum and rectum segments), or a total proctocolectomy (removal of colon, sigmoid and rectum) followed by ileostomy or followed by ileoanal anastomosis.
Laparotomy for other forms of volvulus, especially anal volvulus.
Diverticula may occur in one of the three areas of the esophagus - the pharyngoesophageal, the midesophageal area or the epiphrenic area of esophagus. Zenker's diverticulum is found three times more frequently in men than in women. It occurs posteriorly through the cricopharyngeal muscle in the midline of the neck. Usually seen in people older than 60 years of age.
- Gastric diverticula - "Although usually asymptomatic, they may cause vague epigastric pain. These lesions may be confused radiologically for gastric ulcers or cancers. Endoscopically, they may be confused for paraesophageal hernias."
- Killian-Jamieson diverticulum
- Meckel's diverticulum: a persistent portion of the omphalomesenteric duct present in 2% of the population
- Rokitansky-Aschoff sinuses: in the gallbladder due to chronic cholecystitis
- Traction esophageal diverticulum: due to scarring from mediastinal or pulmonary tuberculosis
- Urethral diverticulum: congenital in males, post-infectious in females
- Zenker's diverticulum: a diverticulum of the mucosa of the pharynx affecting adults
Most of these pathological types of diverticulum are capable of harboring an enterolith. If the enterolith stays in place, it may cause no problems, but a large enterolith expelled from a diverticulum into the lumen can cause obstruction.
Differentiation of DIOS from constipation is generally performed by unit specializing in the treatment of cystic fibrosis. Adequate hydration and an aggressive regimen of laxatives are essential for treatment and prevention of DIOS. Osmotic laxatives such as polyethylene glycol are preferred. Individuals prone to DIOS tend to be at risk for repeated episodes and often require maintenance therapy with pancreatic enzyme replacement, hydration and laxatives (if the symptoms are also mild).
Oral contrast instillation into the colon/ileum under radiological control has been found to reduce the need for surgical intervention.
Diversion colitis is an inflammation of the colon which can occur as a complication of ileostomy or colostomy, often occurring within the year following the surgery. It also occurs frequently in a neovagina created by colovaginoplasty, with varying delay after the original procedure. Despite the presence of a variable degree of inflammation the most suggestive histological feature remains the prominent lymphoid aggregates. A foul smelling, mucous rectal discharge may develop from the inflamed mucosa of the distal, unused colon.
The diagnosis cannot be safely reached without knowing the clinical story. In many milder cases after ileostomy or colostomy, diversion colitis is left untreated and disappears naturally. If treatment is required, possible treatments include short-chain fatty acid irrigation, steroid enemas and mesalazine.
Treatment of accessory pancreas depends on the location and extent of the injured tissue. Surgery may be an option, or some physicians order prophylactic antibiotics.
Equine enteroliths are found by walking pastures or turning over manure compost piles to find small enteroliths, during necroscopy, and increasingly, during surgery for colic. Therefore, the incidence of asymptomatic enteroliths is unknown.
Equine enteroliths typically are smoothly spherical or tetrahedral, consist mostly of the mineral struvite (ammonium magnesium phosphate), and have concentric rings of mineral precipitated around a nidus.
Enteroliths in horses were reported widely in the 19th century, infrequently in the early 20th century, and now increasingly. They have also been reported in zebras: five in a zoo in California and one in a zoo in Wisconsin. Struvite enteroliths are associated with elevated pH and mineral concentrations in the lumen. In California, struvite enteroliths are associated also with a high proportion of alfalfa in the feed and less access to grass pasture. This association has been attributed to the cultivation of alfalfa on serpentine soils, resulting in high concentrations of magnesium in the alfalfa.
A gastrojejunocolic fistula is a disorder of the human gastrointestinal tract. It may form between the transverse colon and the upper jejunum after a Billroth II surgical procedure. (The Billroth procedure attaches the jejunum to the remainder of the stomach). Fecal matter thereby passes improperly from the colon to the stomach, and causes halitosis.
Patients may present with diarrhea, weight loss and halitosis as a result of fecal matter passing through the fistula from the colon into the stomach.
Fecal impaction and attempts at removal can have severe and even lethal effects, such as the rupture of the colon wall by catheter or an acute angle of the fecaloma (stercoral perforation), followed by septicemia. A small fecalith is one cause of both appendicitis and acute diverticulitis. It may also lead to stercoral perforation, a condition characterized by bowel perforation due to pressure necrosis from a fecal mass or fecaloma.
In simple cases of obstruction, where there are no complications, a variety of non-surgical and surgical techniques are used to remove the enterolith. These include crushing the enterolith and milking it back to the stomach or forward to the colon, surgical removal via an uninvolved segment of the gastrointestinal tract, and resection of the involved segment.