Diverticulitis is the term used to describe an inflammation of one or several diverticula. Diverticula are pocket-like protrusions (herniations) of the mucosa through the muscular wall of the small intestine or colon. Typically, they take place in the sigmoid colon, the lower part of the large intestine. The inflammation occurs when the undigested food or bacteria becomes trapped in the structure formed by the diverticula (diverticulum). Diverticulitis is the most common complication of diverticulosis, ie. the presence of diverticula.
Diverticulitis is a common digestive disease that affects both men and women and it is more common in elderly people. The possibility of developing diverticulitis is higher in developed societies and Western countries than underdeveloped countries. Interestingly, there are disparities in the presentation of diverticulosis in different societies. Most notably, while left-sided presentation is common in the West, right-sided diverticulosis is the most frequent form in Asian countries. In the United States, diverticular disease has a substantial clinical impact with an estimated 300,000 related hospitalizations and 1.5 million days of inpatient care per year. It is estimated that approximately 10% of the American population of people over 40 years old have diverticulosis. The incidence increases up to 50% in people over 60 years of age.
Although the exact etiology of the disease is unknown, appearance of diverticulosis appears to be associated with the increased intraluminal pressures. Hard stools from constipation causes not only an elevation of intraluminal pressure, but also stronger muscle contractions that are necessary to move the stool through the intestine. These contractions and increased pressure may facilitate the protrusion of diverticula. Retained food in the diverticula can cause infection and inflammation, ie. diverticulitis. Diets with small amounts of fiber have been implicated in the growth of diverticula.
Diverticulosis typically does not cause any symptoms and most people are unaware that they have diverticulitis. However, when infection and inflammation (divertivulitis) occurs, the following symptoms might be felt:
- Abdominal pain - pain is located at the lower left quadrant of the abdomen. This is a common symptom of diverticulitis. The pain may be intermittent at first but becomes progressively stable.
- Abdominal tenderness
- Nausea and vomiting
- Loss of appetite
- Bleeding from the rectum
- Constipation or diarrhea
Bleeding from the diverticula can be a localized and minor, or a massive hemorrhage. Localized inflammation causes minor bleeding while a hemorrhage can result from the erosion of the blood vessel within the diverticulum.
Diverticulitis can lead to several complications such as:
- Abscess - localized collection of pus that destroys tissue and causes inflammation.
- Perforation due to the infection of the diverticula.
- Peritonitis - infection of the peritoneum after perforation of the diverticula or spreading of diverticulitis.
- Intestinal obstruction – inflammation associated with recurrent diverticulitis can lead to narrowing and obstruction of the bowel.
- Fistula - damaged tissues that stick to each other.
- Shock from excessive bleeding.
There are different diagnostic tests used to identify or to diagnose diverticulitis. Initially, the doctor will ask about previous pain, its location, constipation and presence of rectal bleeding. A physical examination will then be performed, with particular emphasis on the abdominal area to test for distention, tenderness or pain.
Abdominal pain can indicate numerous problems and typically the doctor will need to exclude other causes such as: biliary disease, ovarian cancer, gastric ulcers, inflammatory bowel disease, appendicitis, duodenal ulcers and colon cancer.
To inspect for perforated diverticulum close to the rectum, the doctor may perform a digital rectal examination. After inserting a gloved finger into the rectum the doctor will be able to sense the presence of tender mass, blood or obstruction. An occult blood test should be performed on a stool sample. A complete blood count is usually requested by diverticulitis patients to check for white blood cell count. If elevated, it indicates the presence of infection and supports the diverticulitis diagnosis.
In childbearing women experiencing abdominal pain, the doctor will recommend a pregnancy test to check if she is pregnant, so that proper procedures and medication can be administered without any risk to the fetus. This will also exclude pregnancy related disorders from the diagnosis. When the left ureter is near to a diverticulum, a urinalysis is performed to check for any red blood cells which, if present, indicate perforation.
There are different imaging tests to diagnose diverticulosis/diverticulitis such as:
Barium enema examination shows diverticula of the large intestine.
Colonoscopy is used to evaluate the extent of the disease and to rule out other possibilities or tumors. However, this test is only performed after the acute phase of the disease. During colonoscopy, the doctor inserts a long flexible tube with a light attached to the end (colonoscope) through the anus and into the colon. The doctor can perform biopsy of regions that appear of concern during colonoscopy.
Sigmoidoscopy is a test similar to colonoscopy where the doctor also uses a long and flexible tube with a light attached to the end (now called sigmidoscope) and inserts it through the anus into the sigmoid colon.
Computed tomography (CT) scan is a non-invasive exam and one of the best to confirm the presence of diverticulitis and to check for inflamed diverticulas. This is the most commonly used diagnosis method.
Upper gastrointestinal series shows diverticula of the small intestine and may be used in conjunction with other techniques for a complete scan of the intestine.
Ultrasonography is a non-invasive test that reveals bowel thickening and abscess.
Angiogram is a procedure performed when there is serious bleeding from the intestine. This will locate the source of bleeding in the intestine. This procedure is also called arteriogram.
Treating diverticulitis depends on the severity of the disease. In mild symptomatic cases, a liquid diet is normally recommended with a gradual change into a high fiber diet within a couple of days. Complete bed rest, pain medication and antibiotics may be recommended depending on the exact presentation of the condition.
When there is excessive abscess in the diverticulum, abscess drainage may be performed. The procedure will drain the accumulated pus and alleviate the symptoms. During abscess drainage, the surgeon inserts a fine needle through the skin and places a catheter to draw off the abscess. The catheter may also be used to administer antibiotics directly into the affected area. The procedure is guided by ultrasound or CT scan.
Moderate and severe diverticulitis usually requires hospitalization. Intravenous antibiotics may be administered to control the infection, and surgery may be recommended. The common surgery to address diverticulitis is colon resection which can be performed through the open (traditional) or by the laparoscopic method. There are two types of colon resection: colon resection without colostomy and colon resection with colostomy:
Colon resection without colostomy consists in the removal of the affected part of the intestine and attachment of the unaffected part to the colon. This procedure allows the patient to defecate normally.
Colon resection with colostomy may be necessary when the colon is already very inflamed and the connection of both ends is no longer possible. Rather, the surgeon creates a stoma (opening) in the abdominal area and connects the undamaged part to the stoma. A small pouch is attached to the stoma where the stool is collected.
Preoperative care: The surgery might be performed on an emergency situation or it may be a planned surgery. The surgeon always informs the patient whether a temporary or permanent colostomy might be needed. If the patient is having a severe diverticulitis, a thorough bowel preparation is given one to two days prior to the surgery to avoid perforation.
Postoperative care: After the surgery, the patient will not be given any food or liquids to help the body heal. When the intestine is able to function normally, the patient is given clear liquids slowly.
When diverticulitis becomes complicated, doctors and surgeons will base their treatment approaches in a staging system designated Hinchey's classification. These will serve to guide the choice of the precise surgical intervention to address complicated diverticulitis. There are four stages:
The first stage is characterized by the presence of a small or restricted pericolic or mesenteric abscess.
The second stage is characterized by the presence of a large abscess that is usually restricted in the pelvis.
While in the third stage, a pus-filled peritonitis caused by perforation of the diverticula is observed.
Finally, on the fourth stage the diverticula ruptures and the contents of the intestine fill and contaminate the peritoneal cavity causing widespread infection.
Heat therapy and relaxation techniques that include meditation, deep breathing exercise or massage will help reduce mild pain.
A diet high on fiber may have a great impact in prevention and management of diverticulitis. People with diverticulitis may have deficient nutrient absorption and it is important to ensure a good nutritional status by taking vitamin and mineral supplements.
The prognosis of diverticulitis depends on the incidence of complications and the degree of the situation. The prognosis is normally excellent if adequate treatment and a high-fiber diet are followed. People with mild diverticulitis respond to the treatments very well and hospitalization (if required) is generally short and most patients recover well with bed rest, liquid diet and antibiotics. However, in cases of severe and/or complicated diverticulitis, the prognosis is heavily dependent on how well patients react to the treatments and procedures. Prognosis can be quite reserved in complicated cases with peritonitis. After proper treatment, recurrence of diverticulitis is unlikely, but can be more serious than the initial experience. Seek medical help or support at the first indication of recurring symptoms. Although, with a high impact on patients, colon resection is effective and prevents recurrence of the condition in about 90% of the cases.
People can help prevent the occurrence of diverticulitis by exercising on a regular basis, eating high fiber foods, drinking sufficient amount of liquids and avoiding any delays in bowel movements and other behaviors that lead to increased pressure in the colon. Eating fiber (20 to 35 grams per day), preferably from fruits, vegetables and grains is recommended by the American Dietetic Association.
Depending on the symptoms and severity of the disease, diverticulitis can affect daily activities. Learn as much as you can about the disease and do not under estimate the symptoms. There are several treatments and procedures to manage this disease. It is important to take medication as indicated by your physician and to follow a healthy lifestyle.
Research is ongoing to better evaluate and develop laparoscopic techniques used to treat complicated diverticulitis. In particular, clinical studies are comparing traditional and laparoscopic methods to treat this condition.
There is new data indicating the importance of different factors (such as comorbidity) in assessment of diverticulitis patients. In light of the clinical and economic burden of this disease, some studies are also analyzing the most effective approaches to manage uncomplicated cases.