Diverticular Disease
last authored: March 2011, David LaPierre
last reviewed:
Introduction
Diverticulae (singular - diverticulosis) are small outpouchings of the gastrointestinal tract. They are most common in the colon, but may arise in the pharynx (ie Zenker's diverticulum), esophagus, stomach, and small bowel. Diverticulitis, or inflammation of diverticula, develops in 5-20% of people with diverticula. It can be a life-threatening condition.
Unless otherwise mentioned, diverticular disease refers to that of the colon. Of these, the vast majority occurring in the descending or sigmoid colon.
The Case of Alison Awa
Ms Awa is a 48 year-old woman who presents to the emergency department with a two day history of worsening left lower quadrant pain and fever. She is now in severe distress.
- how do you approach her, in regards to clinical evaluation and investigations?
- if this is diverticulitis, how do you treat her?
Causes and Risk Factors
Colonic diverticulosis is a diet-related disease. In the West, colonic diverticulosis was rare before 1900, but have skyrocketed since the introduction of white flour and a low-residue diet. In Western society, diverticulae are found in 5-10% of adults over 45 and over 50% people over 80. In rural Asia and Africa, rates are 0.2%, though rates increase with immigration.
It was once believed that inflammatory bowel disease preceded diverticulosis, though this is increasingly seen as unlikely.
Meckel's diverticulum begins from ectopic gastric mucosa. They are present near the terminal ileum and are congenital.
Pathophysiology
Colonic diverticula are considered 'false', as they contain only mucosa and submucosathat have herniated through muscle walls following increased intraluminal pressure. A defect in the colonic wall often is seen at sites of nutrient artery penetration.
Diverticular disease begins with infection or perforation of a diverticulum, often facilitated by corticosteroids. It is usual to only have one diverticulum affected at a time. Abscess may result, depending on the size of the perforation. Colonic and small bowel obstruction can follow inflammation.
Signs and Symptoms
- history
- physical exam
History
Colonic diverticulOSIS: The majority of patients are asymptomatic. Symptoms of IBS frequently co-exist with colonic diverticulae, with alternating diarrhea or constipation. Gross blood is rare (Ferzoco, Raptopoulos, and Silen, 1998).
Colonic diverticulITIS:
Patients may experience pain that is:
- usually left lower quadrant pain; right lower quadrant may also be present
- gradual onset
- normally constant, but may be crampy
Other symptoms that may be present include:
- alternating constipation and diarrhea
- nausea and vomiting
- blood in stool
- tenesmus (sensation of incomplete emptying)
- mucous
- urinary frequency and dysuria (if the affected bowel is near the bladder)
- fever, chills, sweats
In some patients, especially the elderly, abdominal pain can be vague, especially, if the disease is retroperitoneal.
Past medical history
- previous bouts of symptoms steer the diagnosis towards diverticulitis
- inflammatory bowel disease
- abdominal or pelvic surgery
- UTI or pyelonephritis
- renal stones
Pharyngeal diverticulae can cause dysphagia, choking, regurgitation, halitosis, and bleeding (hematemesis or melena).
Physical Exam
Vital signs may reveal signs of systemic involvement, including:
- fever
- tachycardia
- hypotension
Abdominal exam should be performed, including digital rectal exam. Evaluate for:
- abdominal mass
- peritoneal signs may be present following perforation
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Initial bloodwork should include:
- CBC (though leukocytosis is seen in only 50% of cases of diverticulitis)
- electrolytes
- BUN, creatinine
In many cases, the distinction between diverticulitis and colon cancer can only be made by a pathologist after biopsy or excision.
Diagnostic Imaging
Abdominal plain film should always be the first modality when investigating abdominal presentations, though has poor sensitivity for diagnosing diverticular disease. Free air may be seen if perforation has occurred.
Divertoculosis may be diagnosed by:
- barium swallow
- endoscopy
- CT scanning
Diverticulitis may be diagnosed by:
- water-soluble contrast enema (barium contraindicated to avoid peritoneal leakage)
- ultrasound
- CT scanning (modality of choice; reveals thickened bowel wall and abscesses)
- rectal contrast can be used to avoid complications with oral or IV administratio
Differential Diagnosis
The differential for diverticular disease includes:
diverticolosis:
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diverticulitis:
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small bowel diverticular disease:
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Treatments
For diverticulosis, a high-fibre diet is the mainstay of treatment. Wheat is the most available and affordable. Medications such as anticholinergics, benzodiazepines, SSRIs, and antibiotics are not helpful. Pain control, if necessary, should avoid opioids.
In diverticulitis, treatments should be tailored according to clinical picture.
Mild
- oral rehydration
- 7-10 day course of liquid diet
- oral ciprofloxacin and metronidazole
Moderate or severe
- admission to hospital
- IV hydration
- NPO, gastric suction
- IV ciprofloxacin and metronidazole
In many cases, abcesses can be treated with CT-guided percutaneous drainage.
Once the acute attack has resolved, a high fibre diet should be gradually instituted. Colonoscopy may be performed after a week or so.
Surgery should considered with:
- worsening clinical picture
- recurrent disease
- sepsis
- fistulization
- obstruction
- peritoneal signs
It is important to stratify patients based on age and underlying medical conditions. Sigmoid resection is most commonly performed, followed by anastamosis or temporary stoma formation (Hartmann procedure).
Consequences and Course
Divertculae can mask bowel malignancy during imaging.
The concequences of diverticulitis can be severe and life-threatening, including
Recurrence occurs in up to a third of cases treated conservatively. Recurrence is higher if there have been more than one episode, or if age is less than 50.
Chronic diverticulitis (>2 months) can cause ongoing pain and obstruction.
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Pharyngeal diverticulae can cause:
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Small bowel disease can cause:
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Worse prognosis is seen in females, free fluid, perforation, and abscess.
Resources and References
Ferzoco LB, Raptopoulos V, and Silen W. 1998. Acute diverticulitis. New England Journal of Medicine 338:1521-1526.
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