Diverticulosis and Diverticulitis
Woman's Diagnostic Cyber Disease Profile
| Name | diverticulosis and diverticulitis |
| Synonyms |
colonic diverticulitis, sigmoid diverticulitis, bowel diverticulum, diverticula, diverticular disease, divertics, acute diverticulitis
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General description |
Diverticulosis is the presence anywhere in the large colon of outpouchings of bowel lining through weak spots in the bowel muscle. It would be analogous to a an inner tube bulging through multiple holes in a tire. It can occur in any or all segments of the larger colon such as the ascending, transverse, descending, or sigmoid colon.
Diverticulitis is inflammation or infection of these pouches. The appendix is a unique, elongated diverticula located at the beginning of the large colon. Inflammation or infection of a diverticula is similar to an appendicitis and has the potential to rupture if untreated. Acute diverticulitis that results in surgical treatment is staged by a classification developed by E. J. Hinchey. The Hinchey classification separates diverticulitis into four stages, I : inflammation around the diverticula itself but confined to the colon (peri-colic abscess), II: pelvic, intraabdominal or retroperitoneal abscess, III: generalized inflammation of the abdominal cavity (peritonitis) with frank pus, and IV: generalized peritonitis with stool in the abdominal cavity. Diverticulosis is asymptomatic in about 70% of people, 5-10% of cases are complicated with bleeding and 10-15% develop diverticulitis.
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| Is it common? |
Diverticulosis increases in frequency with age. About half of Americans aged 60-80 have diverticulosis and over age 80, almost all people have it. In countries where the diet contains much more fiber and less refined food, the incidence is only about 50% that of countries such as the U.S.
Diverticulitis occurs in 10-25% of people with diverticulosis at some time in their lives. Perforation is a much rarer event and happens at about the rate of 4/100000 population per year with women having about half the incidence that men do. |
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Differentiating features |
Diverticulosis usually does not produce any symptoms so there is nothing to differentiate it from. When it does cause problems, it produces mild lower abdominal cramps, bloating, and constipation. When this happens it needs to be differentiated from irritable bowel syndrome and stomach ulcers which can present similar symptoms. Imaging studies showing diverticula will differentiate those.
About 5-10% of people with diverticulosis have rectal bleeding. This needs to be differentiated from internal hemorrhoids that usually produce a painful bowel movement whereas diverticulitis does not. When mucous accompanies the bleeding, it is more often due to diverticulitis. An imaging study that shows large colon diverticula such as a barium enema, a colonoscopy or sigmoidoscopy is needed before making a diagnosis of either diverticulosis or diverticulitis. Diverticulitis causes severe lower abdominal pain, often on the left side but not always. It can also be associated with fever, nausea and vomiting. Previous imaging showing the presence of diverticula is a key differentiating factor. Otherwise it would be diagnosed at time of surgery for an acute abdominal emergency. When the acute pain is on the left side of the abdomen rather than the right side, it is more likely to be due to diverticulitis than appendicitis but that is not a 100% firm rule. |
| Other features | Constipation often precedes the development of diverticula and it also can be a symptom of diverticulosis. Lower abdominal bloating and sometimes nausea are features. |
| Cause |
While the cause of diverticula are unknown for sure, chronic increased intra-colon pressure that eventually forces the bowel lining through weak spots in the colon muscle is suspected to be the primary cause. This is postulated to be due to our modern low fiber diet high in refined foods and leading to a higher frequency of constipation that in turn causes frequent increases in intra-colon pressure.
Infection and inflammation of any diverticula is thought to be due to a blockage at the base of the pouch that blocks secretions, bacteria and food particles to exit the pouch and move further down the bowel with the rest of the stool products. The blockage causes an abscess to form behind it and subsequently to rupture into the abdominal cavity just like an appendicitis. |
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Unnecessary studies |
Stool cultures for bacteria and parasites. |
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Natural history untreated |
If acute diverticulitis is treated but the affected part of the colon is not surgically resected, then the recurrence rate is about 25-85% .
When heavy bleeding requiring hospitalization occurs with no other source found other than the diverticula, about 75% of patients will stop bleeding spontaneously without any surgical intervention. In those who require surgical exploration to stop the bleeding, if the source of the bleeding is found, those patients will only have about a 4% recurrence of bleeding from diverticula. Patients who stop bleeding spontaneously will have recurrent bleeds 38% of the time. |
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Goals of therapy (Rx) |
When diverticula have been detected, the major goal is to prevent any infection or bleeding. This done by preventing constipation using a high fiber diet. |
| 1st choice therapy |
The primary treatment for diverticulosis is a high fiber diet.
The standard treatment for uncomplicated diverticulitis without known bowel or pelvic abscess is bowel rest, with liquid diet or intravenous fluids in combination with antibiotics. For acute diverticulitis in which abscess or rupture is suspected or found on ultrasound or CAT scan (computed abdominal tomography) , surgical treatment with resection of the affected segment of colon and either re-anastomosis or colostomy with re-anastomosis at a second operative procedure is considered the treatment of choice (7). Hinchey stages I and II are usually managed with a one stage operation after drainage of abscess with resection of the offending segment of bowel. Stages III and IV require a two step operation with colostomy placement and re-anastomosis at a later date after the diffuse peritonitis is resolved. |
| Other therapies used |
Partial removal of the colon is often used for interval treatment after a patient has recovered from a diverticulitis flare-up because the recurrence rate is so high.
Treatment with antibiotics prophylactically to try to prevent recurrences of acute diverticulitis has been attempted with some success using rifaximin. |
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Treatments to avoid |
So far, prophylactic antibiotics other than the drug rifaximin have not been shown to prevent recurrences. |
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Reason for Rx choices |
Most patients with diverticula never develop diverticulitis, therefore treatment is conservative with diet and does not include surgery. Major surgery involving resection of an acutely inflamed diverticulitis can carry a high mortality so it is not performed unless abscess formation has taken place. A major goal with acute diverticulitis is to treat with just antibiotics and fluids until the acute infection has resolved. Then surgical resection of the affected colon is performed at much less risk of death or complications. |
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