Die Kolondivertikulose und ihre Komplikationen: Pathogenese, Klassifikation und Klinische Implikationen

 

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Zusammenfassung

Die Pathogenese der „Komplikationen“ der Divertikelkrankheit hat Therapieimplikationen, die hier dargestellt werden. Kolondivertikel in der westlichen Welt sind zumeist Pseudodivertikel (‚Mukosaausstülpungen‘) mit Prädilektionsort im Sigma. Die multifaktorielle Pathogenese umfasst u. a. faserarme Ernährung, Motilitätstörung, Druckerhöhung und morphologische Veränderung der Kolonwand. Der unkomplizierten Sigmadivertikulitis liegen Mikroperforationen zugrunde, entgegen der früheren Hypothese des „abszedierten Divertikels“. Die zumeist verabfolgte Antibiotikatherapie wird aktuell kontrovers diskutiert. Bei den komplizierten Sigmadivertikulitiden liegt zumeist ein durch Makrophagen charakterisiertes Infiltrat vor. Als Risikofaktor für komplizierte Divertikulitiden sind Immunsuppression und insbesondere Steroideinnahme identifiziert. Zur Therapie wird heute in der Regel die elektive bzw. notfallmäßige Resektion empfohlen. Allerdings gibt es auch konträre Konzepte mit rein konservativer Therapie und alleiniger Drainageoperation. Relativ unklar ist die Pathogenese der chronisch-rezidivierenden Divertikulitis. Das frühere Therapiekonzept der Resektion nach dem zweiten Schub ist zugunsten eines risikoadaptierten Vorgehens verlassen worden. Eine Divertikelblutung wird bedingt durch Ruptur eines Vas rectum. Therapeutisch stehen die konservative Behandlung und endoskopische Blutstillung im Vordergrund und bei rezidivierender oder vital bedrohlicher Blutung die chirurgische Resektion, wobei die Lokalisationsdiagnostik (ggf. Angiografie) entscheidend ist. Die komplexe Pathophysiologie der Kolondivertikulose und ihrer „Komplikationen“ ist noch unzureichend verstanden und auch verschiedenste Aspekte der Therapie unterliegen kontroverser Diskussion.

Abstract

Current understanding of the pathogenesis of colonic diverticulosis and its complications has certain implications for current therapy concepts, which are summarised here. Colonic diverticula in the Western world are pseudodiverticula predominating in the sigmoid colon. Pathogenesis is multifactorial and includes low-fibre diet, dysmotility, increased intraluminal pressure and morphological changes. Uncomplicated diverticulitis results from microperforations, contradicting the hypothesis of the “abscessed diverticulum”. Administration of antibiotics for treatment is controversial. Complicated sigmoid diverticulitis is characterised by an intensive inflammatory infiltrate with macrophages. Immunosuppression and especially steroid intake are identified as risk factors. Nowadays, elective or emergency resection is generally recommended as therapy of first choice. However, contrary concepts with merely conservative treatment or drainage – even for perforated diverticulitis – are emerging. The pathogenesis of chronically recurrent diverticulitis is poorly understood and concepts are changing. Resection after the second episode is replaced by a risk-adapted strategy. Diverticular bleeding occurs due to rupture of a vas rectum at the fundus of the diverticulum. Conservative and endoscopic management is the first line and surgical resection plays a role as salvage-strategy in case of recurrent and life-threatening bleeding. Localising the bleeding, i.e., with angiography, is crucial prior to surgery. The pathophysiology of colonic diverticulosis is complex and incompletely understood and linked with several controversial issues, regarding treatment strategies.

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