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Diverticulosis: Symptoms, Causes, Diagnosis, Treatment

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What Are Diverticula?

A diverticulum is a small bulging sac pushing outward from the colon wall. More than one bulging sac is referred to as diverticula.

A diverticulum is a bulging pouch or sac that can form on internal organs. In this slideshow we will discuss colonic diverticula, which are bulging sacs that push outward on the colon wall. Diverticula (plural for "diverticulum") can occur anywhere in the colon, but most commonly form near the end of the colon on the left side (sigmoid colon).

What Is Diverticulitis?

When a diverticulum ruptures and becomes infected, the condition is referred to as diverticulitis.

If a diverticulum becomes inflamed or infected or the area around the diverticulum is swollen, it is called diverticulitis. If the inflammation or infection becomes severe enough, the diverticulum can rupture, spreading bacteria from the colon to the surrounding tissues, causing an infection called peritonitis, or forming a pocket of infection called an abscess.

What Is Diverticulosis?

The condition of having diverticula in the colon is called diverticulosis.

When a patient has diverticula (bulging sacs) in the colon this is called diverticulosis, or diverticular disease.

How Common Is Diverticular Disease?

Diverticular disease is common in the Western world but extremely rare in other areas.

Diverticular disease is most common in industrialized countries where diets are lower in fiber and higher in processed carbohydrates. The U.S., England, and Australia have more cases of diverticular disease than places such as Asia or Africa, where diets are richer in fiber.

Who Gets Diverticular Disease?

Diverticular disease risk increases with age.

In the U.S., diverticular disease is found in more than 50% of people over the age of 60. About 10%-25% of people with diverticular disease will experience an inflammation of a diverticulum, resulting in infection (diverticulitis).

What Causes Diverticula?

The muscular wall of the colon grows thicker with age, and this may reflect the increasing pressures required by the colon to eliminate feces.

Diverticulitis may have multiple causes. Recent studies have suggested both genetic and environmental causes. More traditionally, it has been suggested that diverticula form when there is increased pressure in the colon. This increased pressure has several possible causes. Diets low in fiber cause hard stool and slower "transit time" (the time it takes for stool to pass) through the colon, increasing pressure. In addition, repeated straining during bowel movements also increases pressure. Some medications such as blood pressure medicines, "water pills" (diuretics), and narcotic pain relievers can increase constipation and increase pressure in the colon. Any of these causes of increased pressure can lead to the formation of diverticula.

How Does Diet Contribute To Diverticulosis?

Diverticular disease in developed countries is blamed largely on a low fiber diet.

Diets low in fiber cause stool to be harder and can lead to constipation. Constipation can cause repeated straining during bowel movements and can increase the pressure in the colon, which can lead to the formation of diverticula. Diets higher in fiber can prevent constipation and straining and may decrease the risk for diverticula formation.

What Foods Are High In Fiber?

A diet high in fiber helps prevent constipation and thus decrease the risk for diverticular disease.

There are two types of dietary fiber needed to keep stool soft and to prevent constipation. Soluble fiber dissolves in water and forms a soft gel-like substance in the digestive tract. Insoluble fiber passes through the digestive tract nearly unchanged and can have a laxative effect, helping stool to pass. Good sources of fiber include fruits and vegetables, whole grains, and legumes such as beans or lentils.

What Are the Most Common Symptoms of Diverticular Disease?

Most patients with diverticular disease have few or no symptoms.

Many people with diverticular disease experience no symptoms. About 20% of those affected will experience some symptoms that may include abdominal cramping, bloating, abdominal swelling, rectal pain, and diarrhea.

What Are the Serious Symptoms and Complications of Diverticulitis?

Some patients with diverticular disease experience more serious symptoms and complications.

In some cases, patients may experience severe complications of diverticular disease, including:

  • Severe diverticulitis (infection of the diverticulum)
  • A collection of pus in the pelvis (an abscess) due to rupture of the diverticulum
  • Generalized infection of the abdominal cavity (bacterial peritonitis)
  • Colonic obstruction
  • Bleeding into the colon

What Causes Bleeding With Diverticular Disease?

Bleeding can occur with diverticulosis or diverticulitis, which may be intermittent or continuous.

When the inflammation of the diverticulum erodes into a blood vessel at the base of the diverticulum (sac), this can lead to diverticular bleeding which can cause red, dark, or maroon-colored blood and clots to be passed. Abdominal pain may or may not be present. The bleeding may happen on and off, or last for several days continuously. If there is active bleeding, hospitalization may be necessary. If the bleeding is severe, treatment may be necessary to stop the bleeding, or surgery may be used to remove the diverticula.

When Should I Call the Doctor?

Some symptoms are more serious and the patient should be seen by a doctor.

See your doctor if you have any of the following symptoms and have been diagnosed previously with diverticular disease:

  • Abdominal pain
  • Fever
  • Diarrhea
  • Vomiting
  • Rectal bleeding (even if it stops on its own) – this may be a sign of diverticulosis, diverticulitis, or other serious conditions.

When Should I Go to the Emergency Department?

Some symptoms suggest a complication, and a trip to the emergency department may be warranted.

Go to an emergency department immediately if you have known diverticula or previous bouts of diverticulitis and you experience any of the following symptoms:

  • Severe abdominal pain
  • Persistent fever accompanying abdominal pain
  • Severe vomiting
  • Persistent constipation with abdominal swelling or bloating
  • Severe pain or other symptoms you previously experienced during a bout with diverticulitis

How Is Diverticulitis Diagnosed?

Once suspected, the diagnosis of diverticular disease can be confirmed by a variety of tests.

Diverticula are diagnosed by sigmoidoscopy or colonoscopy, which are scopes with cameras used to look inside the colon. Diverticula can also be diagnosed with an MRI or CT scan of the abdomen and pelvis. Sometimes a barium X-ray (barium enema) is used. During an acute flare-up of diverticulitis, a CT scan may be used to diagnose the extent of the infection.

Few or No Symptoms? What Treatment Is Best?

Many patients do not require any special treatment as they have minimal or no symptoms of diverticular disease.

While many people with diverticular disease have few to no symptoms, a high fiber diet and fiber supplements are recommended to prevent constipation and the formation of additional diverticula.

What Is the Medical Treatment For Mild Abdominal Pain Due To Diverticular Disease?

Some patients with diverticular disease experience abdominal pain due to muscular spasm.

There are some medications that can treat mild symptoms such as abdominal pain due to muscle spasm. Antispasmodic drugs include:

  • chlordiazepoxide (Librax)
  • dicyclomine (Bentyl)
  • hyoscyamine (Levsin)
  • atropine, scopolamine, phenobarbital, hyoscyamine (Donnatal)
  • diphenoxylate and atropine (Lomotil)

In the past doctors advised patients to avoid corn, nuts, and seeds they thought might become lodged in one of the diverticula and cause complications; however, there is no evidence these foods cause any problems. Consult your doctor if you have concerns.

Are Antibiotics Used In the Treatment Of Diverticulitis?

Antibiotics are usually needed when diverticulitis occurs.

If you develop diverticulitis (infection) due to inflamed diverticula, antibiotics may be prescribed for mild symptoms, including:

  • ciprofloxacin (Cipro)
  • levofloxacin (Levaquin)
  • amoxicillin/clavulanic acid (Augmentin)
  • metronidazole (Flagyl)
  • doxycycline (Vibramycin)

If you are experiencing an acute attack of diverticulitis you may be advised to consume a liquid diet and low-fiber foods.

When Is Surgery Necessary for Diverticulitis?

When diverticulitis does not respond to medical treatment, surgical intervention is necessary.

If diverticulitis does not respond to medical treatment, surgery may be required. This usually consists of draining any collections of pus, and surgically removing the segment of the colon where the diverticula are located (usually the sigmoid colon). Persistent bleeding diverticula require surgical removal. Surgery is also necessary in cases where the diverticula erode into other organs such as the adjacent bladder (colovesical fistula), causing severe recurrent urine infections and passage of gas during urination.

Can Diverticular Disease Be Prevented?

Eating a high-fiber diet is the mainstay of diverticular disease prevention.

Diverticula are permanent once formed and can only be removed surgically. There is currently no treatment to prevent diverticular disease. However, diets high in fiber are recommended to increase stool bulk and prevent constipation, which reduces pressure in the colon and may help prevent more diverticula from forming, or worsening of the condition.

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