10 diverticular disease facts
In this article, we will describe 10 diverticular disease facts.
Diverticulae in lower left colon
Key Points
- Diverticular disease encompasses a spectrum of conditions, including asymptomatic diverticulosis, symptomatic diverticular disease, and diverticulitis (inflammation of diverticula).
- It is common in Western populations, particularly among older adults, and is associated with a low-fibre diet.
- Most cases are asymptomatic, but diverticulitis can cause abdominal pain, fever, and altered bowel habits.
- Management depends on the severity, ranging from dietary modification for mild cases to antibiotics and surgery for complications.
- Prevention strategies include increasing dietary fiber intake and promoting a healthy lifestyle.
1. Definition
Diverticular disease refers to the presence of diverticula in the colon (diverticulosis) and its associated complications:
- Diverticulosis: The presence of small, bulging pouches (diverticula) in the colonic wall, usually asymptomatic.
- Diverticular Disease: When diverticulosis becomes symptomatic, often causing intermittent abdominal pain or changes in bowel habits.
- Diverticulitis: Inflammation or infection of the diverticula, leading to more severe symptoms such as abdominal pain, fever, and complications like abscesses or perforation.
2. Epidemiology
- Prevalence: Common in Western countries, affecting around 50% of people over 60 years of age. The prevalence increases with age, with up to 70% of individuals over 80 having diverticula.
- Geographical Variation: More prevalent in developed countries (e.g. UK, USA), where low-fibre diets are common. Less frequent in Asia and Africa, where diets are typically high in fibre.
- Age and Gender: Equally affects men and women, but symptomatic diverticular disease and diverticulitis are more common in individuals over 50 years of age.
3. Risk factors
- Age: The risk of developing diverticulosis and diverticular disease increases significantly with age.
- Low-Fiber Diet: A diet low in fibre is a significant risk factor, leading to harder stools and increased colonic pressure, which can cause diverticula formation.
- Obesity: Linked to an increased risk of developing diverticular disease and its complications.
- Sedentary Lifestyle: Lack of physical activity may contribute to the development of diverticula.
- Smoking: Associated with an increased risk of diverticulitis.
- Use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Long-term use can increase the risk of diverticulitis and its complications.
- Genetics: Family history may play a role, suggesting a genetic predisposition.
4. Causes
Diverticula are thought to form due to increased pressure within the colon, causing the mucosal layer to herniate through weak points in the muscular wall. Factors contributing to this include:
- Low-Fibre Diet: Leads to small, hard stools, requiring greater effort to pass and increasing intraluminal pressure.
- Colonic Motility Disorders: Abnormal contractions of the colon may increase pressure, leading to the formation of diverticula.
- Connective Tissue Changes: Age-related weakening of the colonic wall can predispose to diverticula formation.
5. Symptoms
Diverticulosis
- Often asymptomatic and found incidentally during colonoscopy or imaging for other reasons.
Diverticular disease
- Intermittent Abdominal Pain: Typically in the lower left quadrant, often relieved by passing stool or gas.
- Bloating and Flatulence: Common in symptomatic cases.
- Changes in Bowel Habits: May present with constipation, diarrhea, or alternating bowel patterns.
Diverticulitis
- Acute Abdominal Pain: Usually localised to the lower left quadrant.
- Fever: Indicative of infection or inflammation.
- Nausea and Vomiting: Can occur with more severe inflammation.
- Constipation or Diarrhoea: Altered bowel habits may accompany the pain.
- Tenderness on Palpation: Localised tenderness in the lower abdomen, often with guarding or rebound tenderness.
6. Diagnosis
Clinical diagnosis
- History and examination: Consider diverticular disease in patients over 50 presenting with chronic or recurrent lower abdominal pain. Diverticulitis should be suspected in those presenting with acute left lower quadrant pain, fever, and signs of infection.
- Assessment of risk factors: Identify dietary patterns, smoking history, NSAID use, and family history.
Investigation
- Blood Tests:
- Full Blood Count (FBC): To check for leukocytosis, which indicates infection or inflammation.
- C-Reactive Protein (CRP): Elevated in diverticulitis.
- Imaging:
- Abdominal CT Scan: The gold standard for diagnosing acute diverticulitis. It can identify inflamed diverticula, abscesses, perforation, and other complications.
- Ultrasound: Can be useful, particularly for pregnant patients or those who cannot have a CT scan, but less sensitive than CT.
- Colonoscopy: Not indicated during an acute diverticulitis episode due to the risk of perforation but useful for diagnosing diverticulosis or ruling out other causes of chronic abdominal pain.
Differential diagnosis
- Colorectal Cancer: Presenting with changes in bowel habits, weight loss, or rectal bleeding; should be ruled out, especially in older patients.
- Inflammatory Bowel Disease (IBD): Can mimic diverticular disease, especially with recurrent abdominal pain and altered bowel habits.
- Irritable Bowel Syndrome (IBS): Symptoms of chronic abdominal pain and altered bowel habits but without structural abnormalities.
- Appendicitis: Typically causes right lower quadrant pain, but rare cases can present with left-sided pain, especially in patients with a long appendix.
- Ischemic Colitis: Acute abdominal pain with bloody diarrhoea, particularly in elderly patients with cardiovascular disease.
7. Treatment
Diverticulosis and diverticular disease
- Dietary Modification:
- High-Fibre Diet: Recommended to prevent progression and alleviate symptoms. Patients should aim for 30 g of fibre per day through fruits, vegetables, and whole grains.
- Adequate Hydration: Important to help the passage of stools.
- Pain Management: Simple analgesics like paracetamol are preferred. Avoid NSAIDs due to the risk of diverticulitis.
- Lifestyle Changes: Encourage regular exercise, smoking cessation, and weight management.
Diverticulitis
Mild Cases (Uncomplicated)
- Antibiotics: May be treated as an outpatient with oral antibiotics such as co-amoxiclav or ciprofloxacin with metronidazole. Recent guidelines suggest antibiotics may not always be necessary in mild, uncomplicated cases.
- Clear Liquid Diet: Recommended during acute episodes, with gradual reintroduction of solid foods as symptoms improve.
Moderate to Severe Cases (Complicated)
- Hospital Admission: Required for patients with severe pain, fever, or signs of peritonitis.
- Intravenous Antibiotics: Broad-spectrum coverage with IV antibiotics like ceftriaxone and metronidazole.
- IV Fluids: To maintain hydration and electrolyte balance.
- Surgical Intervention: Indicated for complications such as abscess, perforation, peritonitis, or failure of medical management. Surgical options include resection of the affected bowel segment.
8. Complications
- Abscess Formation: Occurs in 15-30% of diverticulitis cases. May require drainage.
- Bowel Perforation: A life-threatening emergency that can lead to peritonitis.
- Fistula Formation: Abnormal connections between the bowel and adjacent organs (e.g. bladder, vagina).
- Bowel Obstruction: Due to chronic inflammation or scarring.
- Recurrent Diverticulitis: Up to 25% of patients experience recurrence after an initial episode.
9. Prognosis
- Diverticulosis: Generally benign, and most individuals remain asymptomatic throughout their lives.
- Diverticular Disease: Symptomatic cases can have a significant impact on quality of life but are not life-threatening.
- Diverticulitis: Uncomplicated cases have a good prognosis with appropriate treatment, but complications can increase morbidity and require surgical intervention. Recurrent diverticulitis is possible, and preventive strategies are essential.
10. Prevention
- High-Fibre Diet: Increase daily fibre intake to soften stools and decrease colonic pressure, thereby reducing the risk of diverticula formation and symptom recurrence.
- Regular Physical Activity: Helps maintain bowel regularity and overall health.
- Avoiding Smoking and NSAID Use: Reducing these risk factors may help lower the risk of diverticulitis.
- Routine Screening and Follow-Up: For individuals with a history of diverticulitis or other risk factors, regular follow-up by a GP (or hospital based surgeon) can help in early identification and management of any recurrence or complications.
Summary
We have described 10 diverticular disease facts. We hope it has been helpful.
Other resource
MyHSN diverticular disease podcast (2024) – 9 min, 35 sec
