Diverticulosis and Diverticulitis

Diverticulosis is a condition in which small pouches, or diverticula, form in the colon. Diverticulitis is the term used when these pouches become infected or inflamed.

A diverticulum (plural, diverticula) is a small pouch in the colon that bulges outward through weak spots, like an inner tube that pokes through weak places in a tire.



Other Names
Diverticulosis and diverticulitis are also called diverticular disease. The diverticula are sometimes informally referred to as "tics".

Signs and Symptoms
Diverticulosis

Most people with diverticulosis do not have any discomfort or symptoms. However, symptoms may include mild cramps, bloating, and constipation. Other diseases such as irritable bowel syndrome (IBS) and stomach ulcers cause similar problems, so these symptoms do not necessarily mean a person has diverticulosis.

Diverticulitis

The most common symptom of diverticulitis is abdominal pain. The most common sign is tenderness around the left side of the lower abdomen. If infection is the cause, fever, nausea, vomiting, chills, cramping, and constipation may occur as well. The severity of symptoms depends on the extent of the infection and complications.

Causes
Although not proven, the dominant explanation for diverticular disease is that the outpouchings are caused by a low-fiber diet. The disease was first written about in the United States in 1916. At about the same time, processed foods were introduced into the American diet. Many processed foods contain refined, low-fiber flour. Unlike whole-wheat flour, refined flour has no wheat bran.

Diverticular disease is common in developed or industrialized countries&mdash;particularly the United States, England, and Australia&mdash;where low-fiber diets are common. The disease is rare in countries of Asia and Africa, where people eat high-fiber, high-vegetable diets.

Constipation makes intestinal muscles strain to move stool that is too hard. It is the main cause of increased pressure in the colon. This excess pressure, caused perhaps by a low-fiber diet, might cause the weak spots in the colon to bulge out and become diverticula.

Diverticulitis occurs when diverticula become infected or inflamed. Doctors are not certain what causes the infection, but it may begin when stool or bacteria are caught in the diverticula. An attack of diverticulitis can develop suddenly and without warning.

Smoking, alcohol, and caffeine have not been found to be associated with diverticulosis.

Exams and tests
To diagnose diverticular disease, a doctor obtains a medical history, does a physical exam, and may perform one or more diagnostic tests. Because most people do not have symptoms, diverticulosis is often found through tests ordered for another ailment or when patients undergo screening colonoscopy.

When taking a medical history, the doctor may ask about bowel habits, symptoms, pain, diet, and medications. The physical exam usually involves a digital rectal exam. To perform this test, the doctor inserts a gloved, lubricated finger into the rectum to detect tenderness, blockage, or blood. The doctor may check stool for signs of bleeding and test blood for signs of infection.

Typically, if a middle-aged or elderly patient complains of abdominal pain with or without fever, and is tender along the left lower part of the abdomen, diverticular disease is a strong possibility. In younger people, particularly those of Asian descent, the pain of diverticulitis may be on the right (cecal diverticulitis) and is hard to tell apart from appendicitis.

The doctor may also order x-rays or other tests. Commonly used tests include CT scan and colonoscopy. Barium enemas may also be used.

Treatment
Patients who have diverticulosis without symptoms are generally treated with a high-fiber diet. Other treatments aren't usually necessary. Increasing the amount of fiber in the diet may reduce symptoms of diverticulosis and prevent complications such as diverticulitis. Fiber keeps stool soft and lowers pressure inside the colon so that bowel contents can move through easily. The American Dietetic Association recommends 21 to 38 grams of fiber each day.

Treatment for diverticulitis focuses on clearing up the infection and inflammation, resting the colon, and preventing or minimizing complications. An attack of diverticulitis without complications may respond to antibiotics within a few days if treated early. If cramps, bloating, and constipation are problems, the doctor may prescribe a short course of pain medication. However, many pain medications affect emptying of the colon, an undesirable side effect for people with diverticulosis.

To help the colon rest, the doctor may recommend bed rest and a liquid diet, along with a pain reliever.

An acute attack with severe pain or severe infection may require a hospital stay. Most acute cases of diverticulitis are treated with antibiotics and a liquid diet. The antibiotics are given by injection into a vein. In some cases, however, surgery may be necessary. Studies show that 75% of patients who are admitted to the hospital and treated with antibiotics and a clear liquid diet do not need any further treatment.

Medications
A diet high in natural fiber has been extensively studied and shown to reduce diverticulosis. However, some doctors also recommend supplemental fiber, such as Metamucil, in order to increase the amount of fiber in the diet. Supplemental fiber has not been shown to be beneficial, however.

Therapies
If attacks are severe or frequent, surgery is an option. The surgeon removes the affected part of the colon and joins the remaining sections. This type of surgery, called colon resection, aims to keep attacks from coming back and to prevent complications. This type of surgery can usually be done laparoscopically. Surgery may also be recommended for complications of a fistula or intestinal obstruction.

If antibiotics do not correct an attack, emergency surgery may be required. Other reasons for emergency surgery include a large abscess, perforation, peritonitis, or continued bleeding.

Emergency surgery usually involves two operations. The first surgery will clear the infected abdominal cavity and remove part of the colon. Because of infection and sometimes obstruction, it is usually not safe to rejoin the colon during the first operation. Instead, the surgeon creates a temporary hole, or stoma, in the abdomen. The end of the colon is connected to the hole, a procedure called a colostomy, to allow normal eating and bowel movements. The stool goes into a bag attached to the opening in the abdomen. In the second operation, the surgeon rejoins the ends of the colon.

Holistic and alternative treatments
A holistic approach to diverticulosis will include dietary changes such as increasing vegetable intake and avoiding refined foods. Research also suggests that exercise may play a role.

Diet
In a 1971 paper, surgeons Neil S. Painter and Denis P. Burkitt stated, "Diverticular disease is a deficiency disease and, like scurvy, it should be avoidable. By retracing our dietary steps it should be possible to prevent its appearance in future generations and perhaps to lessen the incidence of carcinoma of the colon which has a similar epidemiology." Modern research continues to support this theory.

Avoidance of nuts, popcorn, and sunflower, pumpkin, caraway, and sesame seeds has been recommended by physicians out of fear that food particles could enter, block, or irritate the diverticula. However, no scientific data support this treatment measure. Eating a high-fiber diet is the only requirement highly emphasized across the literature, and eliminating specific foods is not necessary. The seeds in tomatoes, zucchini, cucumbers, strawberries, and raspberries, as well as poppy seeds, are generally considered harmless. People differ in the amounts and types of foods they can eat. Decisions about diet should be made based on what works best for each person. Keeping a food diary may help identify individual items in one's diet.

Physical activity
A study of more than 47,000 American men without diverticulosis found that they were more likely to develop it if they did not engage in vigorous physical activity, jogging, or running.

Lifestyle changes
Dietary changes are the most important in preventing or treating diverticulosis.

Chances of Developing
Diverticulosis is extremely common in developed countries; in the U.S. and Europe, at least half the population is thought to have some diverticula. (For more information, see Epidemiology.

Risk factors
Large studies have shown that a low-fiber diet is the biggest risk factor for developing diverticular disease.

Complications
Diverticulitis can lead to bleeding, infections, perforations or tears, or blockages. These complications always require treatment to prevent them from progressing and causing serious illness.

Bleeding

Bleeding from diverticula is a rare complication. When diverticula bleed, blood may appear in the toilet or in the stool. Bleeding can be severe, but it may stop by itself and not require treatment. Doctors believe bleeding diverticula are caused by a small blood vessel in a diverticulum that weakens and finally bursts.

Abscess, perforation, and peritonitis

The infection causing diverticulitis often clears up after a few days of treatment with antibiotics. If the condition gets worse, an abscess may form in the colon.

An abscess is an infected area with pus that may cause swelling and destroy tissue. Sometimes the infected diverticula may develop small holes, called perforations. These perforations allow pus to leak out of the colon into the abdominal area. If the abscess is small and remains in the colon, it may clear up after treatment with antibiotics. If the abscess does not clear up with antibiotics, the doctor may need to drain it.

To drain the abscess, the doctor uses a needle and a small tube called a catheter. The doctor inserts the needle through the skin and drains the fluid through the catheter. This procedure is called percutaneous catheter drainage. Sometimes surgery is needed to clean the abscess and, if necessary, remove part of the colon.

A large abscess can become a serious problem if the infection leaks out and contaminates areas outside the colon. Infection that spreads into the abdominal cavity is called peritonitis. Peritonitis requires immediate surgery to clean the abdominal cavity and remove the damaged part of the colon. Without surgery, peritonitis can be fatal.

Fistula

A fistula is an abnormal connection of tissue between two organs or between an organ and the skin. When damaged tissues come into contact with each other during infection, they sometimes stick together. If they heal that way, a fistula forms. When diverticulitis-related infection spreads outside the colon, the colon's tissue may stick to nearby tissues. Fistulas most commonly occur with the bladder, small intestine, or skin.

The most common type of fistula occurs between the bladder and the colon. This is called a colovesical fistula. It affects men more than women. This type of fistula can result in a severe, long-lasting infection of the urinary tract. The problem can be corrected with surgery to remove the fistula and the affected part of the colon.

Intestinal obstruction

The scarring caused by infection may cause partial or total blockage of the large intestine. When this happens, the colon is unable to move bowel contents normally. When the obstruction totally blocks the intestine, emergency surgery is necessary. Partial blockage is not an emergency, so the surgery to correct it can be planned.

Comorbidity
A study of over 4,000 patients showed that diverticulitis was not associated with colon polyps or colon cancer.

Clinical Trials
For a list of American government-sponsored clinical trials on diverticular disease, visit ClinialTrials.gov.

Research
Research is ongoing in surgical management of diverticular disease. Recently, scientists hypothesized that diverticuli could be removed from the inside out, using endoscopic therapy (no incisions). They tried this experiment in a pig with success.

Low-residue diet
A common recommendation for treating diverticulosis is a low-residue diet, which means avoiding foods with seeds or pits. This is based on a hypothesis put forth in the 1920s and 1930s that these food items may become lodged in the diverticulum and cause symptoms. However, research has not supported this hypothesis, and current evidence suggests that the low-residue diet is precisely this type of diet that causes diverticulosis.

Expected Outcome
It is estimated that 10%-25% of people with diverticulosis will go on to develop diverticulitis.

History
The condition of diverticulosis was described in the 1800s. However, at that time it was regarded as a surgical curiosity. It was not recognized as a common medical problem until the 1900s; diverticulosis was first mentioned in textbooks as a cause of intestinal performation in 1920. This increase in the incidence of diverticulosis was seen only in highly industrialized countries where eating habits had changed. In Britain, in the 1800s, the ways that flour and other grains were refined changed, and almost all of the fiber was removed from staple foods such as a high-fiber breakfast cereal that had traditionally been eaten daily. The consumption of sugar almost doubled, decreasing the amount of the diet that came from high-fiber foods. For these reasons, Painter hypothesized, in 1971, that diverticulosis was due to a diet high in processed foods.

Etymology
The word diverticulum is thought to have originated from Latin devertere, meaning to turn aside.

Incidence
Between 30 and 55% of the Western population has diverticulosis.