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Ontstaanswijze van diverticulose en diverticulitis

Ontstaanswijze van diverticulose en diverticulitis. Andr é J.P.M. Smout Afd. MDL-ziekten UMC Utrecht. Delft, 29 januari 2008. taenia. taenia. taenia. vasa recta. mesenterium. high pressure. high pressure. pressure . radius . wall tension. Laplace’s law in diverticular disease.

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Ontstaanswijze van diverticulose en diverticulitis

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  1. Ontstaanswijze van diverticulose en diverticulitis André J.P.M. Smout Afd. MDL-ziekten UMC Utrecht Delft, 29 januari 2008

  2. taenia taenia taenia vasa recta mesenterium

  3. high pressure

  4. high pressure

  5. pressure radius wall tension Laplace’s lawin diverticular disease P = k .T / r highest intraluminal pressurein gut segments withsmallest diameter i.e. sigmoid

  6. Colonic manometry

  7. segmenting contractions mass contractions high-amplitude peristaltic contractions do not lead to significant transit lead to transit of large volumes continuously present (day-time) 3-10 times per day Two types of colonic contractions

  8. Two types of colonic contractions 60 cm 50 cm 40 cm 30 cm 20 cm 10 cm 200 mmHg 5 min. segmenting contractions mass contractions high-amplitude peristaltic contractions

  9. health IBS asymptomatic diverticulosis painful diverticular disease Increased colonic motility in diverticular disease Motility Index 1200 1000 800 600 400 200 0 Fasting Postprandial G.H. Ritsema Thesis, Utrecht, 1989

  10. Retrograde HAPC in diverticular disease 1 min transverse descending descending sigmoid sigmoid Bassotti G et al. Dis Colon Rectum 2001;44:1814-1820

  11. Enteric nervous system • Submucosal plexus (Meissner) • Myenteric plexus (Auerbach) Interstitial cells of Cajal • Smooth muscle cells • Circular layer • Longitudinal layer

  12. Altered neuronal regulation in diverticular disease More excitatory (cholinergic) neurons Fewer inhibitory (nitrergic) neurons Tomita R et al. Hepatogastroenterology 2000;47:692-696 Increased sensitivity of smooth muscle to exogenous acetylcholine Huizinga JD et al. Scand J Gastroenterol 1999;34:363-368 Golden M et al. Lancet 2003;361:1945-1951 Reduction of ICCs Bassotti G et al. J Clin Pathol 2005;58:973-979 Golden M et al. Lancet 2003;361:1945-1951

  13. Ageing • Ageing associated with deterioration of collagen in extracellular matrix, mediated by changes in: • matrix metalloproteinases (‘collagenases’) • tissue inhibitors of metalloproteinases Wess LA et al. Gut 1995;37:91-94 Mimura T et al. Dis Colon Rectum 2004;47:371-379

  14. premature development of diverticulosis in connective tissue disorders: • Marfan syndrome • Ehlers-Danlos syndrome • Williams syndrome • scleroderma

  15. connective tissue disorders IBS narrow lumen ageing abnormal colonic motility abnormal collagen weak spots at vasa recti fibre deficiency Pathogenesis of colonic diverticula increased intraluminal pressure weakened wall diverticula

  16. Pathogenesis of diverticulitis

  17. West AB. J Clin Gastroenterol 2006;40:S126-S131 Myochosis Thickening of circular smooth muscle layer

  18. Myochosis  ‘concertina-like’ appearance

  19. Myochosis Hypertrophy or hyperplasia of circular muscle? NEITHER !

  20. muscle cells extracellular matrix Increased elastin content of the taeniae coli (‘elastosis’) Whiteway J Morson BC Gut 1985;26:258-266 elastin fibres increased by at least 200% compared to healthy controls

  21. Myochosis Circular muscle thickened, lumen narrowed and concertina-like appearance caused by shortening of taeniae

  22. Myochosis Myochosis may precede the development of diverticula ‘Prediverticular state’

  23. taenia elastosis myochosis ? Pathogenesis of colonic diverticula connective tissue disorders IBS narrow lumen ageing abnormal colonic motility abnormal collagen weak spots at vasa recti fibre deficiency increased intraluminal pressure weakened wall diverticula

  24. Lancet 1975;7927;211-212

  25. The End

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