Diverticulosis and Diverticulitis

Definition

Diverticulosis refers to a condition in which the inner, lining layer of the large intestine (colon) bulges out (herniates) through the outer, muscular layer. These outpouchings are called diverticula. Diverticulitis refers to the development of inflammation and infection in one or more diverticula.

Description

Diverticula tend to occur most frequently in the last segment of the large intestine, the sigmoid colon. They occur with decreasing frequency as one examines further back toward the beginning of the large intestine. The chance of developing diverticula increases with age, so that by the age of 50, about 20-50% of all people will have some diverticula. By the age of 90, virtually everyone will have developed some diverticula. Most diverticula measure about 3 mm to just over 3 cm in diameter. Larger diverticula, termed giant diverticula, are quite infrequent, but may measure as large as 15 cm in diameter.

Causes and symptoms

Diverticula are believed to be caused by overly forceful contractions of the muscular wall of the large intestine. As areas of this wall spasm, they become weaker and weaker, allowing the inner lining to bulge through. The anatomically weakest areas of the intestinal wall occur next to blood vessels which course through the wall, so diverticula commonly occur in this location.

Diverticula are most common in the developed countries of the West (North America, Great Britain, northern and western Europe). This is thought to be due to the diet of these countries, which tends to be quite low in fiber. A diet low in fiber results in the production of smaller volumes of stool. In order to move this smaller stool along the colon and out of the rectum, the colon must narrow itself significantly, and does so by contracting down forcefully. This causes an increase in pressure, which, over time, weakens the muscular wall of the intestine and allows diverticular pockets to develop.

The origin of giant diverticula development is not completely understood, although one theory involves gas repeatedly entering and becoming trapped in an already-existing diverticulum, causing stretching and expansion of that diverticulum.

The great majority of people with diverticulosis will remain symptom-free. Many diverticula are quite accidentally discovered during examinations for other conditions of the intestinal tract.

Some people with diverticulosis have symptoms such as constipation, cramping, and bloating. It is unclear whether these symptoms are actually caused by the diverticula themselves, or whether some other gastrointestinal condition (such as irritable bowel syndrome ) might be responsible. A complication of diverticulosis occurs because many diverticula develop in areas very near blood vessels. Therefore, one serious risk of diverticulosis involves bleeding. Although an infrequent complication, the bleeding can be quite severe. Seventy-five percent of such bleeding episodes occur due to diverticula located on the right side of the colon. About 50% of the time, such bleeding will stop on its own.

One of the most common and potentially serious complications of diverticulosis is inflammation and infection of a particular diverticulum, called diverticulitis.

Diverticulitis is three times more likely to occur in the left side of the large intestine. Since most diverticula are located in the sigmoid colon (the final segment of the large intestine which empties into the rectum), most diverticulitis also takes place in the sigmoid. The elderly have the most serious complications from diverticulitis, although very severe infections can also occur in patients under the age of 50. Men are three times as likely as women to be stricken with diverticulitis.

Diverticulitis is believed to occur when a hardened piece of stool, undigested food, and bacteria (called a fecalith) becomes lodged in a diverticulum. This blockage interferes with the blood supply to the area, and infection sets in.

An individual with diverticulitis will experience pain (especially in the lower left side of the abdomen) and fever. In response to the infection and the irritation of nearby tissues within the abdomen, the abdominal muscles may begin to spasm. About 25% of all patients with diverticulitis will have some rectal bleeding, although this rarely becomes severe. Walled-off pockets of infection, called abscesses, may appear within the wall of the intestine, or even on the exterior surface of the intestine. When a diverticulum weakens sufficiently, and is filled to bulging with infected pus, a perforation in the intestinal wall may develop. When the infected contents of the intestine spill out into the abdomen, the severe infection called peritonitis may occur. Peritonitis is an infection and inflammation of the lining of the abdominal cavity, the peritoneum. Other complications of diverticulitis include the formation of abnormal connections between two organs that normally do not connect (fistulas; for example, the intestine and the bladder), and scarring outside of the intestine which squeezes off a portion of the intestine, obstructing it.

Diagnosis

As mentioned, the majority of diverticula do not cause any symptoms, and are often found by coincidence during an examination being performed for some other medical condition.

When diverticula are suspected because a patient begins to have sudden rectal bleeding, the location of the bleeding can be studied by performing an angiography. Angiography involves inserting a tiny tube through an artery in the leg, and moving it up into one of the major arteries of the gastrointestinal system. A particular chemical (contrast medium) which will show up on x-ray films is injected, and the area of bleeding is located by looking for an area where the contrast is leaking into the interior (lumen) of the intestine.

A procedure called endoscopy provides another method for examining the colon and locating the site of bleeding. In endoscopy, a small, flexible scope (endoscope) is inserted through the rectum and into the intestine. The scope usually bears a fiber-optic camera, which allows the view through this endoscope to be projected onto a television screen. The operator can introduce the endoscope further and further through the intestine to find the location of the bleeding.

Diagnosis of diverticulitis is not difficult in patients with previously diagnosed diverticulosis. The presence of abdominal pain and fever in such an individual would make the suspicion of diverticulitis quite high. Examination of the abdomen will usually reveal tenderness to touch, with the patient's abdominal muscles contracting strongly to protect the tender area. During a rectal exam (performed by inserting a finger into the rectum), a doctor may be able to feel an abnormal mass. Touching this mass may prove painful to the patient.

When a practitioner is suspicious of diverticulitis as the cause for the patient's symptoms, he or she will most likely avoid the types of tests usually used to diagnose gastrointestinal disorders. These include barium enema and endoscopy. The concern is that the increased pressure exerted on the intestine during these exams may increase the likelihood of intestinal perforation. After medical treatment for the diverticulitis, these examinations may be performed in order to learn the extent of the patient's disease.

Treatment

Only about 20% of patients with diverticulosis ever have symptoms which lead them to seek medical help. Most people never know that they have diverticula. For those individuals who have cramping pain and constipation believed to be due to diverticulosis, the usual prescription involves increasing the fiber in the diet. This can be done by adding special diet supplements of bran or psyllium seed, which increase stool volume. Bleeding diverticula can usually be treated by bed rest, with blood transfusion needed for more severe bleeding (hemorrhaging). In cases of very heavy hemorrhaging, medications which encourage clotting can be injected during the course of a diagnostic angiography.

While there are almost no situations when uncomplicated diverticulosis requires surgery, giant diverticula always require removal. This is due to the very high chance of infection and perforation of these diverticula. When giant diverticula are diagnosed, the usual treatment involves removing that portion of the intestine.

Treatment for uncomplicated diverticulitis usually requires hospitalization. "Resting the bowel" is a mainstay of treatment, and involves keeping the patient from eating or sometimes even drinking anything by mouth. Therefore, the patient will need to receive fluids through a needle in the vein (intravenous or IV fluids). Antibiotics will also be administered through the IV. Some physicians will agree to try treatment at home for very mildly ill patients. These patients will be put on a liquid diet and receive oral antibiotics.

The various complications of diverticulitis need to be treated aggressively, because the death rate from such things as perforation and peritonitis is quite high. Abscesses can be drained of their infected contents by inserting a needle through the skin of the abdomen and into the abscess. When this is unsuccessful, open abdominal surgery will be required to remove the piece of the intestine containing the abscess. Fistulas require surgical repair, including the removal of the length of intestine containing the origin of the fistula, followed by immediate reconnection of the two free ends of intestine. Peritonitis requires open surgery. The entire abdominal cavity is cleaned by being irrigated (washed) with a warmed sterile saltwater solution, and the damaged piece of intestine is removed. Obstructions require immediate surgery to prevent perforation. Massive, uncontrollable bleeding, while rare, may require removal of part or all of the large intestine.

During any of these types of operations, the surgeon must make an important decision regarding the quantity of intestine which must be removed. When the amount of intestine removed is great, it may be necessary to perform a colostomy. A colostomy involves pulling the end of the remaining intestine through the abdominal wall, to the outside. This bit of intestine is then fashioned so that a bag can be fit over it. The patient's waste (feces) collect in the bag, because the intestine no longer connects with the rectum. This colostomy may be temporary, in which case another operation will be required to reconnect the intestine, after some months of substantial healing has occurred. Other times, the colostomy will need to be permanent, and the patient will have to adjust to living permanently with the colostomy bag. Most people with colostomies are able to go on with a very active life.

Occasionally, a patient will have such severe diverticular disease that a surgeon recommends planning ahead, and schedules removal of a portion of the colon. This is done to avoid the high risk of surgery performed after a complication has set in. Certain developments in a patient will identify those patients who are at very high risk of experiencing dangerous complications. Such elective surgery may be recommended:

• when an older individual has had several attacks of diverticulitis
• when someone under the age of 50 has had even one attack
• when treatment does not get rid of a painful mass
• when the intestine appears to be narrowing on x-ray examination (this could suggest the presence of cancer )
• when certain patients begin to regularly experience painful urination or urinary infections (this suggests that there may be a connection between the intestine and the bladder)
• when there is any question of cancer
• when the diverticular disease appears to be progressing rapidly

Prognosis

The prognosis for people with diverticula is excellent, with only 20% of such patients ever seeking any medical help for their condition.

KEY TERMS

Angiography— An x-ray study of the arteries in a particular part of the body. Angiography is often performed in order to localize internal bleeding.

Bowel obstruction— A blockage in the intestine which prevents the normal flow of waste down the length of the intestine.

Colostomy— A procedure performed when a large quantity of intestine is removed. The end piece of the intestine leading to the rectum is closed.

Diverticula— Outpouchings in the large intestine caused when the inner, lining layer of the large intestine (colon) bulges out (herniates) through the outer, muscular layer.

Endoscopy— Examination of an area of the gastrointestinal tract by putting a lighted scope, usually bearing a fiber-optic camera, into the rectum, and passing it through the intestine.

Fistula— An abnormal connection formed between two organs that usually have no connection whatsoever.

Sigmoid colon— The final portion of the large intestine that empties into the rectum.

While diverticulitis can be a difficult and painful disease, it is usually quite treatable. Prognosis is worse for individuals who have other medical problems, particularly those requiring the use of steroid medications, which increase the chances of developing a serious infection. Prognosis is also worse in the elderly.

Prevention

While there is no absolutely certain way to prevent the development of diverticula, it is believed that high-fiber diets are of help. Foods that are recommended for their high fiber content include whole grain breads and cereals, and all types of fruits and vegetables. Most experts suggest that individuals take in about 0.71-1.23 oz (20-35) gs of fiber daily. If this is not possible to achieve through a person's diet, there are fiber products which can be mixed into 8 oz (237l) of water or juice, and which provide about 0.13-19 oz (4-6 gs) of fiber.

Resources

ORGANIZATIONS

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. (800) 891-5389. 〈http://www.niddk.nih.gov/health/digest/nddic.htm〉.