Diverticulitis, specifically colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—diverticula—which can develop in the wall of the large intestine. Symptoms typically include lower abdominal pain of sudden onset, but onset may also occur over a few days. In North America and Europe the abdominal pain is usually on the left lower side (sigmoid colon), while in Asia it is usually on the right (ascending colon). There may also be nausea; and diarrhea or constipation. Fever or blood in the stool suggests a complication. Repeated attacks may occur.
|Other names||Colonic diverticulitis|
|Section of large bowel (sigmoid colon) showing multiple pouches (diverticula). The diverticula appear on either side of the longitudinal muscle bundle (taenium) which runs horizontally across the specimen in an arc.|
|Symptoms||Abdominal pain, fever, nausea, diarrhea, constipation, blood in the stool|
|Complications||Abscess, fistula, bowel perforation|
|Usual onset||Sudden, age > 50|
|Risk factors||Obesity, lack of exercise, smoking, family history, nonsteroidal anti-inflammatory drugs|
|Diagnostic method||Blood tests, CT scan, colonoscopy, lower gastrointestinal series|
|Differential diagnosis||Irritable bowel syndrome|
|Treatment||Antibiotics, liquid diet, hospital admission|
|Frequency||3.3% (developed world)|
The causes of diverticulitis are uncertain. Risk factors may include obesity, lack of exercise, smoking, a family history of the disease, and use of nonsteroidal anti-inflammatory drugs (NSAIDs). The role of a low fiber diet as a risk factor is unclear. Having pouches in the large intestine that are not inflamed is known as diverticulosis. Inflammation occurs in between 10% and 25% at some point in time, and is due to a bacterial infection. Diagnosis is typically by CT scan, though blood tests, colonoscopy, or a lower gastrointestinal series may also be supportive. The differential diagnosis includes irritable bowel syndrome.
Preventive measures include altering risk factors such as obesity, inactivity, and smoking. Mesalazine and rifaximin appear useful for preventing attacks in those with diverticulosis. Avoiding nuts and seeds as a preventive measure is no longer recommended since there is no evidence these play a role in initiating inflammation in diverticula. For mild diverticulitis, antibiotics by mouth and a liquid diet are recommended. For severe cases, intravenous antibiotics, hospital admission, and complete bowel rest may be recommended. Probiotics are of unclear use. Complications such as abscess formation, fistula formation, and perforation of the colon may require surgery.
The disease is common in the Western world and uncommon in Africa and Asia. In the Western world about 35% of people have diverticulosis while it affects less than 1% of those in rural Africa, and 4 to 15% of those may go on to develop diverticulitis. The disease becomes more frequent with age, being particularly common in those over the age of 50. It has also become more common in all parts of the world. In 2003 in Europe, it resulted in approximately 13,000 deaths. It is the most frequent anatomic disease of the colon. Costs associated with diverticular disease were around US$2.4 billion a year in the United States in 2013.
Signs and symptoms
Diverticulitis typically presents with lower quadrant abdominal pain of sudden onset. In North America and Europe the abdominal pain is usually on the left lower side (sigmoid colon), while in Asia it is usually on the right (ascending colon). There may also be fever, nausea, diarrhea or constipation, and blood in the stool.
In complicated diverticulitis, an inflamed diverticulum can rupture, allowing bacteria to subsequently infect externally from the colon. If the infection spreads to the lining of the abdominal cavity (the peritoneum), peritonitis results. Sometimes, inflamed diverticula can cause narrowing of the bowel, leading to an obstruction. In some cases, the affected part of the colon adheres to the bladder or other organs in the pelvic cavity, causing a fistula, or creating an abnormal connection between an organ and adjacent structure or other organ (in the case of diverticulitis, the colon and an adjacent organ).
Related pathologies may include:
The causes of diverticulitis are poorly understood, with approximately 40 percent due to genes and 60 percent due to environmental factors. Conditions that increase the risk of developing diverticulitis include arterial hypertension and immunosuppression. Obesity is another risk factor. Low levels of vitamin D are associated with an increased risk of diverticulitis.
It is unclear what role dietary fibre plays in diverticulitis. It is often stated that a diet low in fibre is a risk factor; however, the evidence to support this is unclear. There is no evidence to suggest that the avoidance of nuts and seeds prevents the progression of diverticulosis to an acute case of diverticulitis. It appears in fact that a higher intake of nuts and corn could help to avoid diverticulitis in adult males.
Right-sided diverticula are micro-hernias of the colonic mucosa and submucosa through the colonic muscular layer where blood vessels penetrate it. Left-sided diverticula are pseudodiverticula, since the herniation is not through all the layers of the colon. Diverticulitis is postulated to develop because of changes inside the colon, including high pressures because of abnormally vigorous contractions.
People with the above symptoms are commonly studied with computed tomography, or CT scan. The CT scan is very accurate (98%) in diagnosing diverticulitis. In order to extract the most information possible about the person's condition, thin section (5 mm) transverse images are obtained through the entire abdomen and pelvis after oral and intravascular contrast have been administered. Images reveal localized colon wall thickening, with inflammation extending into the fat surrounding the colon. The diagnosis of acute diverticulitis is made confidently when the involved segment contains diverticula. CT may also identify people with more complicated diverticulitis, such as those with an associated abscess. It may even allow for radiologically guided drainage of an associated abscess, sparing a person from immediate surgical intervention.
Classification by severity
- Stage 0 - asymptomatic diverticulosis
- Stage 1a - uncomplicated diverticulitis
- Stage 1b - diverticulitis with phlegmonous peridiverticulitis
- Stage 2a - diverticulitis with concealed perforation, and abscess with a diameter of one centimeter or less
- Stage 2b – diverticulitis with abscess greater than one centimeter
- Stage 3a – diverticulitis with symptoms but without complications
- Stage 3b – relapsing diverticulitis without complications
- Stage 3c – relapsing diverticulitis with complications
The severity of diverticulitis can be radiographically graded by the Hinchey Classification.
The differential diagnosis includes colon cancer, inflammatory bowel disease, ischemic colitis, and irritable bowel syndrome, as well as a number of urological and gynecological processes. In those with uncomplicated diverticulitis, cancer is present in less than 1% of people.
Most cases of simple, uncomplicated diverticulitis respond to conservative therapy with bowel rest.
People may be placed on a low fibre diet. It was previously thought that a low-fibre diet gives the colon adequate time to heal. Evidence tends to run counter to this, with a 2011 review finding no evidence for the superiority of low fibre diets in treating diverticular disease, and that a high-fibre diet may prevent diverticular disease. A systematic review published in 2012 found no high-quality studies, but found that some studies and guidelines favour a high-fibre diet for the treatment of symptomatic disease. While it has been suggested that probiotics may be useful for treatment, the evidence currently neither supports nor refutes this claim.
The use of antibiotics in mild cases of uncomplicated diverticulitis is supported with only "sparse and of low-quality" evidence, with no evidence supporting their routine use. In spite of this, antibiotics are recommended by several current guidelines. With CT scan evidence of abscess, fistula, or intestinal rupture with peritonitis, antibiotics are recommended and routinely used.
Indications for surgery are abscess or fistula formation; and intestinal rupture with peritonitis. These, however, rarely occur. Surgery for abscess or fistula is indicated either urgently or electively. The timing of the elective surgery is determined by evaluating factors such as the stage of the disease, the age of the person, their general medical condition, the severity and frequency of the attacks, and whether symptoms persist after the first acute episode. In most cases, elective surgery is deemed to be indicated when the risks of the surgery are less than the risks of the complications of the diverticulitis. Elective surgery is not indicated until at least six weeks after recovery from the acute event. Emergency surgery is indicated for intestinal rupture with peritonitis.
The first surgical approach consists of resection and primary anastomosis. This first stage of surgery is performed on people if they have a well-vascularized, nonedematous and tension-free bowel. The proximal margin should be an area of pliable colon without hypertrophy or inflammation. The distal margin should extend to the upper third of the rectum where the taenia coalesces. Not all of the diverticula-bearing colon must be removed, since diverticula proximal to the descending or sigmoid colon are unlikely to result in further symptoms.
Diverticulitis surgery consists of a bowel resection with or without colostomy. Either may be done by the traditional laparotomy or by laparoscopic surgery. The traditional bowel resection is made using an open surgical approach, called colectomy. During a colectomy the person is placed under general anesthesia. A surgeon performing a colectomy will make a lower midline incision in the abdomen or a lateral lower transverse incision. The diseased section of the large intestine is removed, and then the two healthy ends are sewn or stapled back together. A colostomy may be performed when the bowel has to be relieved of its normal digestive work as it heals. A colostomy implies creating a temporary opening of the colon on the skin surface, and the end of the colon is passed through the abdominal wall with a removable bag attached to it. The waste is collected in the bag.
However, most surgeons prefer performing the bowel resection laparoscopically, mainly because postoperative pain is reduced with faster recovery. The laparoscopic surgery is a minimally invasive procedure in which three to four smaller incisions are made in the abdomen or navel. Alternately, laparoscopic sigmoid resection (LSR) compared to open sigmoid resection (OSR) showed that LSR is not superior over OSR for acute symptomatic diverticulitis. Furthermore, laparoscopic lavage was as safe as resection for perforated diverticulitis with peritonitis.
All colon surgery involves only three maneuvers that may vary in complexity depending on the region of the bowel and the nature of the disease. The maneuvers are the retraction of the colon, the division of the attachments to the colon and the dissection of the mesentery. After the resection of the colon, the surgeon normally divides the attachments to the liver and the small intestine. After the mesenteric vessels are dissected, the colon is divided with special surgical staplers that close off the bowel while cutting between the staple lines.
Bowel resection with colostomy
When excessive inflammation of the colon renders primary bowel resection too risky, bowel resection with colostomy remains an option. Also known as the Hartmann's operation, this is a more complicated surgery typically reserved for life-threatening cases. The bowel resection with colostomy implies a temporary colostomy which is followed by a second operation to reverse the colostomy. The surgeon makes an opening in the abdominal wall (a colostomy) which helps clear the infection and inflammation. The colon is brought through the opening and all waste is collected in an external bag.
The colostomy is usually temporary, but it may be permanent, depending on the severity of the case. In most cases several months later, after the inflammation has healed, the person undergoes another major surgery, during which the surgeon rejoins the colon and rectum and reverses the colostomy.
Diverticulitis most often affects the elderly. In Western countries, diverticular disease most commonly involves the sigmoid colon (95 percent of people with diverticulitis). The number of people affected with diverticular disease increased from an estimated 10 percent in the 1920s to between 35 and 50 percent by the late 1960s. 65 percent of people over 85 can be expected to have some form of diverticular disease of the colon. Less than 5 percent of those aged 40 years and younger are affected by diverticular disease.
Left-sided diverticular disease (involving the sigmoid colon) is most common in the West, while right-sided diverticular disease (involving the ascending colon) is more common in Asia and Africa. Among people with diverticulosis, 4 to 15% may go on to develop diverticulitis.
- "Diverticular Disease". www.niddk.nih.gov. September 2013. Archived from the original on 13 June 2016. Retrieved 12 June 2016.
- Tursi, A (March 2016). "Diverticulosis today: unfashionable and still under-researched". Therapeutic Advances in Gastroenterology. 9 (2): 213–28. doi:10.1177/1756283x15621228. PMC 4749857. PMID 26929783.
- Pemberton, John H (16 June 2016). "Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis". UpToDate. Archived from the original on 2017-03-14. Retrieved 13 March 2017.
- Feldman, Mark (2010). Sleisenger & Fordtran's Gastrointestinal and liver disease pathophysiology, diagnosis, management (9th ed.). [S.l.]: MD Consult. p. 2084. ISBN 9781437727678. Archived from the original on 2016-08-08.
- Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Churchill Livingstone. 2014. p. 986. ISBN 9781455748013. Archived from the original on 2016-08-08.
- Young-Fadok, TM (October 2018). "Diverticulitis". New England Journal of Medicine. 379 (17): 1635–42. doi:10.1056/NEJMcp1800468. PMID 30354951.
- Templeton, AW; Strate, LL (August 2013). "Updates in diverticular disease". Current Gastroenterology Reports. 15 (8): 339. doi:10.1007/s11894-013-0339-z. PMC 3832741. PMID 24010157.
- Böhm, Stephan K. (29 April 2015). "Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking". Viszeralmedizin. 31 (2): 84–94. doi:10.1159/000381867. PMC 4789955. PMID 26989377.
- Ferguson LR, Laing B, Marlow G, Bishop K (January 2016). "The role of vitamin D in reducing gastrointestinal disease risk and assessment of individual dietary intake needs: Focus on genetic and genomic technologies". Mol Nutr Food Res. 60 (1): 119–33. doi:10.1002/mnfr.201500243. PMID 26251177.
- Weisberger, L; Jamieson, B (July 2009). "Clinical inquiries: How can you help prevent a recurrence of diverticulitis?". Journal of Family Practice. 58 (7): 381–2. PMID 19607778.
- Morris, AM; Regenbogen, SE; Hardiman, KM; Hendren, S (Jan 15, 2014). "Sigmoid diverticulitis: a systematic review". JAMA. 311 (3): 287–97. doi:10.1001/jama.2013.282025. PMID 24430321.
- Lee, Kyoung Ho; Lee, Hye Seung; Park, Seong Ho; Bajpai, Vasundhara; Choi, Yoo Shin; Kang, Sung-Bum; Kim, Kil Joong; Kim, Young Hoon (2007). "Appendiceal Diverticulitis". Journal of Computer Assisted Tomography. 31 (5): 763–9. doi:10.1097/RCT.0b013e3180340991. PMID 17895789.
- "CT scan of diverticulitis". ClariPACS. 2017. Retrieved 19 June 2017.
- Horton, KM; Corl, FM; Fishman, EK (2000). "CT evaluation of the colon: inflammatory disease". Radiographics. 20 (2): 399–418. doi:10.1148/radiographics.20.2.g00mc15399. PMID 10715339.
- Sai, V. F.; Velayos, F; Neuhaus, J; Westphalen, A. C. (2012). "Colonoscopy after CT Diagnosis of Diverticulitis to Exclude Colon Cancer: A Systematic Literature Review". Radiology. 263 (2): 383–390. doi:10.1148/radiol.12111869. PMC 3329267. PMID 22517956.
- Tursi, A (2015). "The role of colonoscopy in managing diverticular disease of the colon" (PDF). Journal of Gastrointestinal and Liver Diseases. 24 (1): 85–93. doi:10.15403/jgld.2014.1121.tur. PMID 25822438. Archived (PDF) from the original on 2017-08-10.
- Kruse, E; Leifeld, L (April 2015). "Prevention and Conservative Therapy of Diverticular Disease". Viszeralmedizin. 31 (2): 103–6. doi:10.1159/000377651. PMC 4789966. PMID 26989379.
- Klarenbeek, B. R.; De Korte, N; Van Der Peet, D. L.; Cuesta, M. A. (2011). "Review of current classifications for diverticular disease and a translation into clinical practice". International Journal of Colorectal Disease. 27 (2): 207–214. doi:10.1007/s00384-011-1314-5. PMC 3267934. PMID 21928041.
- Rottier, SJ; van Dijk, ST; van Geloven, AAW; Schreurs, WH; Draaisma, WA; van Enst, WA; Puylaert, JBCM; de Boer, MGJ; Klarenbeek, BR; Otte, JA; Felt, RJF; Boermeester, MA (July 2019). "Meta-analysis of the role of colonoscopy after an episode of left-sided acute diverticulitis". The British Journal of Surgery. 106 (8): 988–997. doi:10.1002/bjs.11191. PMC 6618242. PMID 31260589.
- Spirt, Mitchell (2010). "Complicated Intra-abdominal Infections: A Focus on Appendicitis and Diverticulitis". Postgraduate Medicine. 122 (1): 39–51. doi:10.3810/pgm.2010.01.2098. PMID 20107288.
- Tarleton, S; DiBaise, JK (April 2011). "Low-residue diet in diverticular disease: putting an end to a myth". Nutrition in Clinical Practice. 26 (2): 137–42. doi:10.1177/0884533611399774. PMID 21447765.
- Ünlü, C; Daniels, L; Vrouenraets, BC; Boermeester, MA (April 2012). "A systematic review of high-fibre dietary therapy in diverticular disease". International Journal of Colorectal Disease. 27 (4): 419–27. doi:10.1007/s00384-011-1308-3. PMC 3308000. PMID 21922199.
- Lahner, E; Bellisario, C; Hassan, C; Zullo, A; Esposito, G; Annibale, B (March 2016). "Probiotics in the Treatment of Diverticular Disease. A Systematic Review". Journal of Gastrointestinal and Liver Diseases. 25 (1): 79–86. doi:10.15403/jgld.2014.1121.251.srw. hdl:11573/866049. PMID 27014757.
- de Korte N, Unlü C, Boermeester MA, Cuesta MA, Vrouenreats BC, Stockmann HB (June 2011). "Use of antibiotics in uncomplicated diverticulitis". Br J Surg. 98 (6): 761–7. doi:10.1002/bjs.7376. PMID 21523694.
- Merck, Sharpe & Dohme. "Diverticulitis treatments" Archived 2010-03-06 at the Wayback Machine 2010-02-23.
- What's the diverticulitis surgery? Archived 2010-02-27 at the Wayback Machine Digestive Disorders portal. Retrieved on 2010-02-23
- Diverticulitis: Treatment & Medication Archived 2010-03-16 at the Wayback Machine eMedicine. 2010-02-23
- Diverticulitis Surgery Archived 2010-02-12 at the Wayback Machine 2010-02-23
- Gupta, Aditya K.; Chaudhry, Maria; Elewski, Boni (2003). "Tinea corporis, tinea cruris, tinea nigra, and piedra". Dermatologic Clinics. 21 (3): 395–400, v. doi:10.1016/S0733-8635(03)00031-7. PMID 12956194.
- Ahmed, Ali Mahmoud; Mohammed, Abdelrahman Tarek; Mattar, Omar Mohamed; Mohamed, Esraa Mowafy; Faraag, Esraa Abdelmon'em; AlSafadi, Ammar Mohammed; Hirayama, Kenji; Huy, Nguyen Tien (1 July 2018). "Surgical treatment of diverticulitis and its complications: A systematic review and meta-analysis of randomized control trials". The Surgeon. 20 (6): 372–383. doi:10.1016/j.surge.2018.03.011. PMID 30033140.
- Bowel resection procedure Archived 2010-01-29 at the Wayback Machine Encyclopedia of surgery. Retrieved on 2010-02-23
- Diverticulitis treatments and drugs Archived 2010-02-12 at the Wayback Machine Mayo Clinic. 2010-02-23
- Vermeulen J, Coene PP, Van Hout NM, van der Harst E, Gosselink MP, Mannaerts GH, Weidema WF, Lange JF (July 2009). "Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure?". Colorectal Disease. 11 (6): 619–24. doi:10.1111/j.1463-1318.2008.01667.x. PMID 18727727.