Diverticulosis and diverticulitis facts
- Most patients with diverticulosis (diverticular disease) have few or no symptoms.
- Abdominal pain, constipation, and diarrhea, can occur with diverticulosis, which then may be called diverticular disease.
- Diverticulosis can be diagnosed with barium X-rays, sigmoidoscopy, colonoscopy, or CT scan.
- Treatment of diverticulosis can include high fiber diet, and anti-spasmodic drugs.
- When diverticulosis is associated with inflammation and infection the condition is called diverticulitis.
- Complications of diverticulosis and diverticulitis include rectal bleeding, abdominal infections, and colon obstruction.
What is diverticulosis?
The colon (large intestine) is a long tube-like structure that stores and then eliminates waste material left over after digestion of food in the small intestine takes place. Pressure within the colon causes bulging pockets of tissue (sacs) that push out from the colonic walls as a person ages. A small bulging sac pushing outward from the colon wall is called a diverticulum. More than one bulging sac is referred to in the plural as diverticula. Diverticula can occur throughout the colon but are most common near the end of the left colon, referred to as the sigmoid colon, in Western countries. In Asia, the diverticula occur mostly on the right side of the colon. The condition of having these diverticula in the colon is called diverticulosis.
Diverticula are common in the Western world but are rare in areas such as Asia and Africa. Diverticula increase with age. They are uncommon before the age of 40, and are seen in more than 74% of people over the age of 80 years in the U.S. A person with diverticulosis usually has few or no symptoms. The most common symptoms associated with diverticulosis are abdominal pain, constipation, and diarrhea. In some of these patients the symptoms may be due to the concomitant presence of irritable bowel syndrome or abnormalities in the function of the muscles of the sigmoid colon (diverticular disease); simple diverticula should cause no symptoms. Occasionally, bleeding originates from a diverticulum, and it is referred to as diverticular bleeding.
What is diverticulitis?
When a diverticulum ruptures and infection sets in around the diverticulum, the condition is called diverticulitis. An individual suffering from diverticulitis often has abdominal pain, abdominal tenderness, colonic obstruction and fever.
What are diverticulitis symptoms?
Most patients with diverticulosis have few or no symptoms. The diverticulosis in these individuals is found incidentally during tests for other intestinal problems. It has been thought s many as 20% of individuals with diverticulosis will develop symptoms related to diverticulosis, primarily diverticulitis; however, the most recent study suggests that the incidence is closer to 5%.
The most common signs and symptoms of diverticulitis include:
- Abdominal pain (left lower abdomen)
- Abdominal tenderness (left lower abdomen)
- Constipation or, sometimes, diarrhea.
What causes diverticula, and how do diverticula form?
The muscular wall of the colon grows thicker with age, although the cause of this thickening is unclear. It may reflect the increasing pressures required by the colon to eliminate feces. For example, a diet low in fiber can lead to small, hard stools which are difficult to pass and which require increased pressure to pass. The lack of fiber and small stools also may allow segments of the colon to close off from the rest of the colon when the colonic muscle in the segment contracts. The pressure in these closed-off segments may become high since the increased pressure cannot dissipate to the rest of the colon. Over time, high pressures in the colon push the inner intestinal lining outward (herniation) through weak areas in the muscular walls. These pouches or sacs that develop are called diverticula.
Lack of fiber in the diet has been thought to be considered the most likely cause of diverticula, and there is a good correlation among societies around the world between the amount of fiber in the diet and the prevalence of diverticula. Nevertheless, studies have not found similar correlations between fiber and diverticuli within individual societies. Many people with diverticular disease have excessive thickening of the muscular wall of the colon where the diverticula form. The muscle also contracts more strongly. These abnormalities of the muscle may be contributing factors in the formation of diverticula. Microscopic examination of the edges of the diverticula show signs of inflammation, and it has been suggested that there may be an inflammatory component to the formation of the diverticula.
What are the more serious complications of diverticulitis?
More serious complications of diverticulitis include:
- Collections of pus (abscess) in the pelvis where the diverticulum has ruptured
- Colonic obstruction
- Generalized infection of the abdominal cavity (bacterial peritonitis)
- Bleeding into the colon
A diverticulum can rupture, and the bacteria within the colon can spread into the tissues surrounding the colon (diverticulitis). Constipation or diarrhea also may occur. A collection of pus can develop around the ruptured diverticulum, leading to formation of an abscess, usually in the pelvis. Inflammation surrounding the colon also can lead to colonic obstruction. Infrequently, a diverticulum ruptures freely into the abdominal cavity causing a life threatening infection called peritonitis. On rare occasions, the inflamed diverticula can erode into the urinary bladder, causing bladder infection and passing of intestinal gas in the urine.
Diverticular bleeding occurs when the expanding diverticulum erodes into a blood vessel within the diverticulum. Rectal passage of red, dark or maroon-colored blood and clots occur without any associated abdominal pain if there is no diverticulitis, but bleeding into the colon also may occur during and episode of diverticulitis. Blood from a diverticulum of the right colon may be black in color. Bleeding may be continuous or intermittent, lasting several days.
Patients with active bleeding usually are hospitalized for observation. Intravenous fluids are given to support the blood pressure. Blood transfusions are necessary for those with moderate to severe blood loss. In a rare individual with brisk and severe bleeding, the blood pressure may drop, causing dizziness, shock, and loss of consciousness. In most patients, bleeding stops spontaneously and they are sent home after several days in the hospital. Patients with persistent, severe bleeding require surgical removal of the bleeding diverticula.
How are the diagnosis of diverticulitis and diverticulosis made?
If suspected, the diagnosis of diverticular disease can be confirmed by a variety of tests. Barium X-rays (barium enemas) can be performed to visualize the colon. Diverticula are seen as barium filled pouches protruding from the colon wall.
Direct visualization of the inside of the colon and the openings of the diverticula can be done with flexible tubes inserted through the rectum and advanced into the colon. Either short tubes (sigmoidoscopes) or longer tubes (colonoscopes) may be used to assist in the diagnosis and to exclude other diseases that can mimic diverticular disease.
In patients suspected of having diverticulitis causing persistent pain, tenderness, and fever; ultrasound and computerized tomography (CT) examinations of the abdomen and pelvis can be done to detect inflammation of the tissues surrounding the ruptured diverticulum or collections of pus.
What is the treatment for diverticulitis and diverticulosis?
Treatment for diverticulitis and diverticulosis include medications to treat abdominal pain due to muscle spasms, oral antibiotics for infection, and liquid or low fiber foods when having a acute attacks of diverticulitis.
Medical treatment of diverticulitis and diverticulosis
Most patients with diverticulosis have minimal or no symptoms, and do not require any specific treatment. A normal fiber diet is advisable to prevent constipation and perhaps prevent the formation of more diverticula.
Patients with mild symptoms of abdominal pain due to muscular spasm in the area of the diverticula may benefit from anti-spasmodic drugs such as:
- chlordiazepoxide (Librax),
- dicyclomine (Bentyl),
- atropine, scopolamine, phenobarbital (Donnatal), and
- hyoscyamine (Levsin).
When diverticulitis occurs, antibiotics usually are needed. Oral antibiotics are sufficient when symptoms are mild. Some examples of commonly prescribed antibiotics include:
Liquid or low fiber foods are advised during acute attacks of diverticulitis. This is done to reduce the amount of material that passes through the colon, which at least theoretically, may aggravate the diverticulitis. In severe diverticulitis with high fever and pain, patients are hospitalized and given intravenous antibiotics. Surgery is needed for patients with persistent bowel obstruction or abscess not responding to antibiotics.
Surgical treatment for diverticulitis
Diverticulitis that does not respond to medical treatment requires surgical intervention. Surgery usually involves drainage of any collections of pus and resection (surgical removal) of the segment of the colon containing the diverticula, usually the sigmoid colon. Surgical removal of the bleeding diverticulum also is necessary for those with persistent bleeding. In patients needing surgery to stop persistent bleeding, it is important to determine exactly where the bleeding is coming from in order to guide the surgeon.
Sometimes, diverticula can erode into the adjacent urinary bladder, causing severe recurrent urine infection and passage of gas during urination. This situation also requires surgery.
Sometimes, surgery may be suggested for patients with frequent, recurrent attacks of diverticulitis leading to multiple courses of antibiotics, hospitalizations, and days lost from work. During surgery, the goal is to remove all, or almost all, of the colon containing diverticula in order to prevent future episodes of diverticulitis. There are few long-term consequences of resection of the sigmoid colon for diverticulitis, and the surgery often can be done laparoscopically, which limits post-operative pain and time for recovery.
What can be done to prevent diverticulitis and diverticulosis?
Once formed, diverticula are permanent. No treatment has been found to prevent complications of diverticular disease.
Diets high in fiber increases stool bulk and prevents constipation, and theoretically may help prevent further diverticular formation or worsening of the diverticular condition. Some doctors recommend avoiding nuts, corn, and seeds, which are thought by some to plug diverticular openings and cause diverticulitis, but there is little evidence to support this recommendation.
Because inflammation has been found at the edges of diverticula, it has been speculated that colonic bacteria may be playing a role in the rupture of diverticula by promoting inflammation. This has led some people to further speculate that changing the bacteria in the colon might reduce inflammation and rupture and to suggest treatment with probiotics; however, there is not enough evidence of a benefit of probiotics yet to recommend treatment with probiotics of patients with diverticular disease.