I diverticoli sono protrusioni sacciformi della parete del colon, di dimensioni variabili da pochi millimetri a vari centimetri. Il termine diverticolosi indica semplicemente la presenza di diverticoli multipli del colon.
La prevalenza della malattia diverticolare nella popolazione generale varia tra il 35 e il 50%. Tale prevalenza è direttamente proporzionale all’età, e si valuta che sia del 65% a 85 anni.
Molti ritengono che la dieta contribuisca notevolmente allo sviluppo della malattia diverticolare, ma è probabile che l’etiologia comprenda anche fattori tuttora non riconosciuti.
Gli studi clinici condotti hanno considerato che la dieta con basso contenuto di fibre predispone allo sviluppo dei diverticoli alterando la motilità del colon. I diverticoli tendono a svilupparsi in punti specifici sulla circonferenza del colon: tale localizzazione è determinata, in parte, dai rapporti anatomici tra la muscolatura del viscere e i vasi che lo irrorano. Anche la distribuzione di queste erniazioni in tutto il colon tende a seguire un andamento caratteristico. La stragrande maggioranza dei diverticoli si sviluppano nel colon discendente e nel sigma.
La maggior parte dei pazienti con diverticolosi restano asintomatici per tutta la vita, oppure lamentano dolori addominali continui o intermittenti (al quadrante inferiore sinistro dell’addome, prevalentemente), o irregolarità dell’alvo e/o di meteorismo. Si calcola che sintomi e segni della diverticolite si sviluppino in circa il 10-25% dei casi. Un altro 15% di pazienti giungono all’osservazione con un’emorragia da diverticoli. Come nella maggior parte delle condizioni, la prognosi di ciascun episodio di emorragia o di flogosi varia a seconda delle condizioni generali di salute e della gravità del processo morboso responsabile. Gli individui con diverticolite modesta possono essere trattati conservativamente con ottimi risultati, mentre quelli con perforazione in peritoneo libero necessitano di un intervento chirurgico urgente.
Dopo il primo episodio di diverticolite, circa un terzo dei pazienti subiscono un secondo attacco, in genere entro 3-5 anni.
Indagini diagnostiche
- Clisma opaco: dimostra bene i diverticoli, è indicato soprattutto in urgenza per confermare il sospetto diagnostico.
- Colonscopia: permette di definire la diagnosi nonchè di porre diagnosi differenziale fra “tumore infiammatorio” da diverticolite e carcinoma del colon (biopsie).
- Tac addome: è particolarmente utile, in urgenza, allorchè permette di stabilire la presenza di complicazioni della malattia diverticolare.
La complicanza principale della diverticolosi e la diverticolite: il quadro clinico è caratterizzato dalla presenza di febbre, leucocitosi e dolore addominale a prevalente localizzazione in fossa iliaca sinistra.
Le possibili complicanze possono essere la perforazione, con conseguente peritonite diffusa che richiede l’intervento chirurgico in urgenza, o la formazione di un ascesso peridiverticolare (le cui pareti sono costituite da anse intestinali e omento). In casi particolari la presenza di un ascesso può essere risolta con il drenaggio della raccolta sotto guida tac, altre volte è necessario, per la comparsa di un quadro settico, l’intervento chirurgico. L’esito dell’ascesso non drenato può essere la formazione di una fistola tra colon e visceri vicini (es.: vescica, vagina; oppure la cute) che, talvolta, è particolarmente difficile da trattare.
Trattamento della diverticolite
- Digiuno; terapia reidratante per via venosa;
- Copertura antibiotica.
L’intervento chirurgico diviene indispensabile per drenare un ascesso già formato (ma il drenaggio e possibile anche per via percutanea, in ecografia) o in caso di perforazione e peritonite.
Si può eseguire in urgenza una resezione del tratto di colon patologico e una colonstomia provvisoria; più rara e la possibilità di ricostruzione (anastomosi) immediata.
L’intervento e necessario anche in caso di emorragia grave o recidivante (resezione più o meno estesa del colon interessato); oppure per trattare fistole stercoracee con la vescica o la vagina.
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