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What are a diverticulum and diverticula?
A diverticulum is a small bulging sac pushing outward from the colon wall. More than one bulging sac is referred to as diverticula. Diverticula can occur throughout the colon but are most common near the end of the left colon called the sigmoid colon.
What is diverticulitis?
A diverticulum can rupture. The rupture allows bacteria within the colon to spread into the tissues surrounding the colon. The resulting infection is called diverticulitis.
What is diverticulosis?
Diverticulosis is a condition where a patient has diverticula in the colon. A patient who has diverticulosis of the colon is referred to as having diverticular disease.
How common is diverticular disease?
Diverticular disease is more common in developed or industrialized countries, for example, the United States, England, and Australia, where the diet is typically low in fiber and high in highly processed carbohydrates. Diverticular disease is much less common in countries where the diet is typically high in fiber, for example, Asia and Africa.
Who gets diverticular disease?
Diverticular disease is uncommon before the age of 40, but is seen in more than 50% of people over the age of 60 in the United States. Approximately 10%-25% of people with diverticular disease develop diverticulitis (rupture followed by infection).
What causes diverticula?
As the body ages, the muscular layer of the intestinal wall thickens. This causes the open space inside the colon to narrow. Stool moves more slowly through the colon, increasing the pressure. Hard stools (such as those produced by a low fiber diet) or a slower "transit time" through the colon can also increase pressure. Frequent, repeated straining during bowel movements also increases pressure and may contribute to the formation of diverticula.
How does diet contribute to diverticulosis?
A diet low in fiber can create hard stools, and lead to constipation. As mentioned previously, with frequent and repeated straining during bowel movements, pressure inside the colon increases and contributes to the formation of diverticula. Adding more fiber to the diet can help prevent constipation and may decrease the risk for diverticular disease.
What foods are high in fiber?
Fiber is found in fruits, vegetables, whole grains, and legumes (dried beans, peas, and lentils). There are two types of fiber, soluble (dissolves in water) and insoluble.
- Soluble fiber forms a soft gel-like substance in the digestive tract.
- Insoluble fiber passes through the digestive tract nearly unchanged.
- Both of these are necessary to keep stool soft and moving easily through the digestive tract to prevent constipation.
What are the most common symptoms of diverticular disease?
Most patients with diverticular disease do not have symptoms; however, 20% of patients with diverticular disease will develop symptoms including:
- abdominal cramping,
- constipation, and
These symptoms are related to difficulty passing stool along the left colon narrowed by diverticular disease.
What are the serious symptoms and complications of diverticulitis?
More serious symptoms and complications of diverticular disease include:
- diverticulitis (rupture or infection of the diverticulum),
- a collection of pus in the pelvis (an abscess),
- colonic obstruction,
- generalized infection of the abdominal cavity (bacterial peritonitis), and
- bleeding into the colon.
What causes bleeding with diverticular disease?
Diverticular bleeding occurs when the expanding diverticulum erodes into a blood vessel at the base of the diverticulum. The patient may pass red, dark, or maroon-colored blood and clots without any associated abdominal pain. Bleeding may be intermittent or continuous (lasting several days). Patients with active bleeding usually are hospitalized for monitoring. Patients with persistent, severe bleeding require surgical removal of the diverticula.
When should I call the doctor?
A patient should see their healthcare provider if they have persistent:
- abdominal pain,
- unexplained fevers,
- diarrhea, or
If a patient has rectal bleeding they should see their health care provider even if the bleeding stops on its own. Bleeding may be a sign of diverticulosis, diverticulitis, or other serious diseases.
When should I go to the emergency department?
The following symptoms suggest a complication and warrant an immediate visit to an emergency department.
- Worsening abdominal pain
- Persistent fever with abdominal pain
- Vomiting so severe that the patient can't keep anything down
- Persistent constipation for an extended period of time.
- Severe pain or other symptoms that the patient had previously when they had diverticulitis.
How is diverticulitis diagnosed?
Diverticula can be seen via barium X-ray (barium enema). The diverticula are seen as barium filled pouches protruding from the colon wall. Direct visualization of the colon can be achieved through flexible sigmoidoscopy or colonoscopy. In patients suspected of having a diverticular abscess causing persistent pain and fever, ultrasound and CT scan of the abdomen and pelvis can be done to detect collections of pus.
What is the treatment for a patient with diverticular disease with minimum or no symptoms?
Many patients with diverticular disease have minimal or no symptoms and thus do not require specific treatment. A high fiber diet and fiber supplements are recommended to prevent constipation and formation of more diverticula.
What is the medical treatment for mild abdominal pain due to diverticular disease?
Patients with mild symptoms (for example, abdominal pain due to muscular spasm in the area of the diverticula) may benefit from anti-spasmodic drugs such as:
- chlordiazepoxide (Librax),
- dicyclomine (Bentyl),
- hyoscyamine (Levsin),
- atropine, scopolamine, phenobarbital, hyoscyamine (Donnatal), and
- diphenoxylate and atropine (Lomotil)
Some doctors recommend the avoidance of nuts, corn, and seeds to prevent complications of diverticulosis, but it is uncertain if these dietary restrictions are beneficial.
Are antibiotics used in the treatment of diverticulitis?
When diverticulitis occurs, oral antibiotics are sufficient when symptoms are mild. Examples of commonly prescribed antibiotics include:
- ciprofloxacin (Cipro),
- metronidazole (Flagyl), and
- doxycycline (Vibramycin).
Liquid or low fiber foods are advised during acute attacks of diverticulitis.
When is surgery necessary for a patient with diverticulitis?
Diverticulitis that does not respond to medical treatment requires surgical intervention. Surgery usually involves drainage of any collections of pus and surgical removal of the segment of the colon containing the diverticula (usually the sigmoid colon). Surgical removal of bleeding diverticula is necessary for patients with persistent bleeding. Sometimes the diverticula can erode into the adjacent bladder, causing severe recurrent urine infections and passage of gas during urination. This situation also requires surgery.
Can diverticular disease be prevented?
Once formed, diverticula are permanent. No treatment has been found to prevent complications of diverticular disease. Diets high in fiber increases stool bulk and prevents constipation, and theoretically may help prevent further diverticular formation or worsening of the diverticular condition. As mentioned previously, some doctors recommend avoiding nuts, corn, and seeds which can plug diverticular openings and cause diverticulitis. Whether avoidance of such foods is beneficial is unclear.
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