Diverticulosis/Diverticulitis

What is Diverticular disease?

Diverticular disease, also called ‘diverticulosis’, is a condition where little pouches or pockets develop in the large bowel (colon). These pockets (called ‘diverticulum’) are created secondary to pressure on weak areas of the muscle layer of the bowel. It is a normal process of aging and most people develop some diverticular disease in their later years.

‘ Diverticulitis ‘ is inflammation of a diverticulum. “itis” is latin for inflammation. This occurs when a diverticulum is blocked or becomes infected. Diverticulitis tends to be episodic and can vary in severity and duration.

What are the symptoms of diverticular disease and diverticulitis?

  1. aDiverticular disease (Diverticulosis): Most people have no symptoms from diverticular disease. Typically, the first time someone learns that they have diverticulosis is when they have a colonoscopy or a CT scan for another reason.

A minority of people however do experience symptoms which include:

abdominal pain – often triggered during periods of constipation and relieved by a bowel movement.

constipation – diverticular disease can cause scarring leading to angulation and narrowing of the colon.  This can cause, or worsen already existing, constipation.

Bleeding – generally caused by irritation around the opening of a diverticulum which exposes an underling blood vessels and leads to bleeding.  The bleeding is usually brisk with a large amount of blood passed into the colon in a short period of time. Fortunately, most of the time the bleeding stops on its own and is rarely life threatening.  Nevertheless urgent medical attention is recommended if significant bleeding occurs. 

2. Diverticulitis: if a diverticulum or a group of diverticula become infected, acute pain in the left lower portion of the abdomen occurs and is often associated with fever and chills. Bleeding occurs to some extent in most cases. In severe cases, the inflamed diverticulum (or diverticula) can rupture leading to a localized abscess, or more worryingly to diffuse abdominal pain and uncontrolled infection.

Diverticulitis

How do you diagnose diverticular disease and diverticulitis?

If there is presence of symptoms consistent with diverticular disease (e.g. left lower abdominal pain), diverticulosis can be diagnosed with a thorough clinical evaluation combined with imaging (CT scan or MRI) and/or colonoscopy.

Diverticulitis is often diagnosed in the Emergency Department through a combination of blood tests and a CT scan of the abdomen. In addition to signs of inflammation, a CT scan will also look for an associated abscess or ruptured diverticulum.

After you have received proper treatment and the inflammation has resolved, most patients will be sent for colonoscopy to make sure there are no obstructive lesions (e.g. a large polyp or tumor) that may have provoked the episode of diverticulitis.

How do you treat diverticular disease and diverticulitis?

Diverticular disease found incidentally and causing no symptoms does not require any specific treatment.

Pain associated with diverticular disease is treated through dietary modification and by preventing constipation.  Diet is the most important part and many patients can achieve a symptom free life without the need to take any medications.  There is also evidence that diet can also help reduce the risk of worsening diverticulosis as well as the risk of recurrent diverticulitis.(1)  A personalized diet developed in conjunction with a dietitian can help achieve these goals. 

Diverticulitis requires either oral or IV antibiotics (depending on the severity) followed by a specialized diet to prevent recurrence.  A severe attack may require admission to hospital for several days for supportive care, IV antibiotics and surgical assessment.

If there is evidence of a perforated diverticulum on CT scan, the type of intervention will depend on whether the infection is contained inside an abscess or not.  If it is contained inside an abscess, a CT guided drainage can be used. If the infection is diffuse and if there is evidence in of persistent infection coming from the colon, surgery may be necessary.  During the surgery, the infectious debris will be cleaned out of the abdomen and the perforated portion of the colon will be removed.

Unfortunately, diverticulitis can recur.  While prevention with dietary modification is important to minimize this risk, it may not be enough.  After multiple episodes of uncomplicated diverticulitis, it may be recommended to remove the area of the colon affected by diverticulosis.  This is a significant operation and the decision should be made in consultation with your gastroenterologist and a colorectal surgeon.

1) Crowe FL, Appleby PN, Allen NE, Key TJ. Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): Prospective study of British vegetarians and non-vegetarians. BMJ 2011;343:d4131.