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Content provided by Jon Lund
Clinical Associate Professor, School of Graduate Entry Medicine & Health, University of Nottingham 		 
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Diverticular Disease

Diverticular Disease

1. Definitions

1.1 Diverticulum

A diverticulum is an abnormal outpouching of a hollow viscus into the surrounding tissues.
In regards to diverticulum of the colon, these are abnormal outpouchings of mucosa and submucosa through the muscle wall of the colon. These can be true or false diverticula.

1.1.1 True Diverticula

A diverticulum that contains all the layers of the wall of the viscus from which it protrudes e.g. Meckel's diverticulum, bladder diverticulum.

1.1.2 False Diverticula

A diverticulum that contain only some of the layers of the wall of the viscus

1.2 Diverticulosis

This is the condition of having diverticula in the large bowel, most commonly found in the sigmoid colon.

1.3 Diverticulitis

This condition develops from pre-existing diverticulosis, and results when diverticula become inflamed.

 

2. Epidemiology

  •  Incidence increases with age
  • Common in developed countries and uncommon in Africa and Asia
  • Left sided disease common in the West, right sided more common in Africa and Asia
  • 5% affected in their 5th decade of life
  • 50% affected by their 9th decade of life

     

    3. Aetiology

    • Old age
    • Low fibre diet
    • Constipation
    • Obesity
    • High fibre diet + plenty of exercise = reduced risk of diverticulosis!

     

    4. Pathophysiology

    •  It is an acquired condition
    • Mucosa and submucosa herniates through the circular muscle layer at weak points in the wall.
    • Diverticula are thought to develop due to raised intraluminal pressure secondary to a low fibre diet and constipation.
    • Low fibre diet increases the frequency and intensity of colonic contractions leading to increases in intraluminal pressure

     

    5. Complications of diverticulosis

    • Diverticulitis
    • Abscess formation
    • Strictures
    • Bleeding
    • Perforation
    • Peritonitis
    • Sepsis
    • Fistula

     

    6. Symptoms

    • Majority of people remain asymptomatic
    • See the links at the bottom of the page to read patient experiences of diverticular disease

    6.1 Diverticulosis

    • PR bleeding -
      • painless pr bleeding
      • due to erosion of a vessel at the base of the diverticulum
      • most frequent cause of pr bleeding in the elderly
      • classically co-existing inflammation is absent
      • can be severe and required hospitalisation
    • Bloating
    • Abdominal pain - colicky in nature
    • Change of bowel habit - diarrhoea/constipation

    6.2 Diverticulitis

    • Abdominal pain - typically left sided
    • Fever
    • Constipation

    6.3 Abscess

    • Abdominal pain
    • Swinging pyrexia

     6.4 Fistula

    • Most common is a colo-vesical fistula
      • Recurrent UTI's
      • Pneumaturia

     

    7. Diagnosis

    •  History and examination
    • Bloods -
      • should all be normal in uncomplicated diverticulosis
      • Typically a leucocytosis is seen in diverticulitis

    7.1 Diverticulosis

    7.1.1 Colonoscopy

    • colonoscopy diverticular disease Colonoscopy is the most useful test
    • It demonstrates diverticulae, mucosal inflammation, and most importantly excludes other pathology i.e. malignancy
    • Should be performed when patient is asymptomatic i.e. no acute symptoms are present
    • After an acute attack, should be performed 4-6 weeks post-discharge

    7.1.2 Barium Enema

    • Contraindicated during acute episode

    7.1.3 Computed Tomography Colonography

    • Role is still evolving

     

    7.2 Diverticulitis + Other complications

    7.2.1 Computed Tomography (CT)

    • With oral and intravenous contrast
    • Investigation of choice in acute episode
    • Can be used as a diagnostic and therapeutic tool

     

    • Diagnostic
      • Able to demonstrate the extent of inflammation, abscess formation and visualise fistulas
    • Therapeutic
      • CT guided percutaneous drainage can be performed on localised pericolic diverticular abscesses

       

    8. Management

     

    8.1 Conservative

    8.1.1 Asymptomatic diverticulosis

    • No treatment is required
    • Dietary advice
      • increase fibre + vegetables in diet
      • increase fluid intake
    • Avoidance of constipation + constipating drugs

    8.1.2 Diverticulitis

    • Nil by mouth (bowel rest)
    • IV Antibiotics (Cef & Met)

    8.1.3 Pericolic Abscess

    • Nil by mouth
    • IV Antibiotics
    • Can be treated by CT guided percutaneous drainage

     

    8.2 Surgical

    8.2.1 Emergency

    8.2.1.1 Indications

    • Peritonitis - usually secondary to either
      • perforated diverticulum leading to faecal peritonitis
      • pericolic abscess leading to purulent peritonitis
    • Pericolic abscess unresponsive to conservative management and not possible for percutaneous drainage

    8.2.1.2 Hartmann's

    • This is the operation of choice for emergency left sided complicated diverticulitis
    • The diseased segment of bowel is removed and an end colostomy is formed
    • In the presence of sepsis, primary anastomosis is not possible due to the increased risk of anastomotic leak post-op
    • A temporary end colostomy is formed which will be reversed 3-6 months later once the patient has made a full recovery

     

    8.2.2 Elective

    8.2.2.1 Indications 

    • All colonic fistulae
    • Recurrent attacks of diverticulitis
    • Strictures - leading to symptoms of sub-acute obstruction

    8.2.2.2 Colonic resection + primary anastomosis

    • As sepsis is generally absent in the elective setting the operation of choice would be a colonic resection of the diseased segment of colon with primary anastomosis

     

    9. Resources

    National Organisation for Diverticular Disease - patient experiences
    http://www.diverticulitis.org.uk/diverticulitis-stories.htm
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