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Diverticulitis

What is diverticulitis? Diverticulitis is a condition in which diverticuli in the colon rupture. The rupture results in infection in the tissues that surround the colon.

What is diverticulosis? The colon (large intestine) is a long tube-like structure that stores and then eliminates waste material. 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 as diverticula. Diverticula can occur throughout the colon but are most common near the end of the left colon called the sigmoid colon. The condition of having these diverticula in the colon is called diverticulosis.

A patient with diverticulosis may have few or no symptoms. When a diverticulum ruptures and becomes infected, the condition is called diverticulitis. A patient suffering from diverticulitis will have abdominal pain, abdominal tenderness, and fever. When bleeding originates from a diverticulum, it is called diverticular bleeding. A patient who suffers the consequences of diverticulosis in the colon is referred to as having diverticular disease.

Diverticular disease is common in the Western world but is extremely rare in areas such as Asia and Africa. Diverticular disease increases with age. It is uncommon before the age of forty, and is seen in more than fifty percent of people over the age of sixty in the United States. Whereas most patients with diverticular disease have no or few symptoms, some patients will develop bleeding, rupture and infection (diverticulitis), constipation, abdominal cramps, and even colonic obstruction.

How do diverticula form? The muscular wall of the colon grows thicker with age. Thickening of the colon wall may reflect the increasing pressures required by the colon to eliminate feces. A diet low in fiber can lead to small, hard stools which are difficult to pass. Over time, vigorous contractions in the colon push the inner intestinal lining outwards (herniates) through cracks in the muscle walls. These pouches or sacs that develop are called diverticula.

What are the symptoms of diverticular disease? Most patients with diverticulosis have few or no symptoms. The diverticulosis condition in these individuals is found incidentally during tests for other intestinal problems. Twenty percent of patients with diverticulosis will develop symptoms related to diverticulosis. The most common symptoms of diverticular disease include: • abdominal cramping, • constipation, and • diarrhea.

These symptoms are related to difficulty of passing stool along the left colon narrowed by diverticular disease. More serious complications include: • diverticulitis, • collection of pus (abscess) in the pelvis, • colon obstruction, • generalized infection of the abdominal cavity (bacterial peritonitis), and • bleeding into the colon.

A diverticulum can rupture, and the bacteria within the colon can spread into the tissues surrounding the colon causing diverticulitis. Constipation or diarrhea may also occur. A collection of pus can develop around the inflamed diverticulum, leading to formation of an abscess, usually in the pelvis. On rare occasions, the inflamed diverticula can erode into the urinary bladder, causing bladder infection and passing of gas during urination. Inflammation in the colon can also lead to bowel obstruction. Infrequently, a diverticulum ruptures freely into the abdominal cavity causing a life threatening infection called peritonitis.

Diverticular bleeding occurs when the expanding diverticulum erodes into a blood vessel at the base of a diverticulum. Rectal passage of red, dark or maroon-colored blood and clots occur without any associated abdominal pain. Rarely, blood may be black from a diverticulum of the right colon. Bleeding may be continuous or intermittent, lasting several days.

Patients with active bleeding usually are hospitalized for monitoring. 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 can 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 is the diagnosis of diverticular disease made? Once 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 intestine 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 diverticular abscess causing persistent pain and fever, ultrasound and CT scan examinations of the abdomen and pelvis can be done to detect collections of pus fluid.

What is the treatment for diverticular disease? Medical treatment for diverticulitis Many patients with diverticulosis have minimal or no symptoms, and do not require any specific treatment. A high fiber diet and fiber supplements are advisable to prevent constipation and the formation of more diverticula. Patients with mild symptoms abdominal pain due to muscular spasm in the area of the diverticula may benefit from anti-spasmodic drugs such as: • chlordiazepoxide (Librax), • dicyclomine (Bentyl), • hyoscyamine, atropine, scopolamine, phenobarb (Donnatal), and • hyoscyamine (Levsin).

Some doctors also recommend avoidance of nuts, corn, and seeds to prevent complications of diverticulosis. Whether these dietary restrictions are beneficial is uncertain.

When diverticulitis occurs, antibiotics are usually needed. Oral antibiotics are sufficient when symptoms are mild. Some examples of commonly prescribed antibiotics include: • ciprofloxacin (Cipro), • metronidazole (Flagyl), • cephalexin (Keflex), and • doxycycline (Vibramycin).

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, might aggravate the diverticulitis. In severe diverticulitis with high fever and pain, patients are hospitalized and given intravenous antibiotics. Surgery is needed for those with persistent bowel obstruction or abscess not responding to antibiotics.

Surgery 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 that segment of the colon containing the diverticuli, usually the sigmoid colon. Therefore, surgical removal of the bleeding diverticula is necessary for those with persistent bleeding. In patients needing surgery to stop persistent bleeding, exact localization becomes crucial to guide the surgeon.

Sometimes, diverticula can erode into the adjacent 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 diverticular disease? 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 can plug diverticular openings and cause diverticulitis. Whether avoidance of such foods is beneficial is unclear.

Patients with known diverticular disease who develop unexplained fever, chills or abdominal pain should notify their doctor because of the possibility of the complication of diverticulitis. A better understanding of the way diverticula form and become infected will hopefully lead to discovery of more effective ways to manage these common conditions.

Diverticulosis At A Glance • When diverticulosis is associated with inflammation and infection the condition is called diverticulitis. • Most patients with diverticulosis have few or no symptoms. • Abdominal cramping, constipation, diarrhea, bloating can be symptoms of diverticulosis. • Diverticular disease can be diagnosed with barium x-rays or with sigmoidoscopy or colonoscopy. • Treatment of diverticulosis can include high fiber diet, and anti-spasmodic drugs. • Complications of diverticulosis include rectal bleeding, diverticulitis with abdominal infection, and colon obstruction.