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Diverticulitis

Diverticulitis is a common disease of the bowel, specifically the large intestine. Diverticulitis develops from diverticulosis, which involves the formation of pouches, referred as diverticula, on the outside of the colon. Diverticulitis results if one of the diverticula becomes inflamed.

Complications

In complicated diverticulitis, bacteria may subsequently infect the outside of the colon, if an inflamed diverticulum bursts open. If the infection spreads to the lining of the abdominal cavity, namely the peritoneum, this can cause a potentially fatal peritonitis. Sometimes inflamed diverticula can cause narrowing of the bowel, leading to an obstruction. Also the affected part of the colon could adhere to the bladder or other organs in the pelvic cavity, causing a fistula, or abnormal communication between the colon and an adjacent organ.

In a nutshell, the complications include:

Bowel obstruction
Peritonitis
Abscess
Fistula
Bleeding
Strictures

Incidence

Diverticulitis most often affects middle-aged and elderly persons, though it can strike younger patients as well. Abdominal obesity may be associated with diverticulitis in younger patients, with some being as young as 20 years old.

In 95% of patients in western countries, diverticular disease involves the sigmoid colon. The prevalence of diverticular disease has increased from an estimated 10% in the 1920s to between 35 and 50% by the late 1960s. 65% of those currently 85 years of age and older can be expected to have some form of diverticular disease of the colon. Less than 5% of those aged 40 years and younger may also be affected by diverticular disease. Many have described diverticulitis as passing gas from the penile opening.

Left-sided diverticular disease, involving the sigmoid colon, is most common in the West, while right-sided diverticular disease is more prevalent in Asia and Africa.

Among patients with diverticulosis, 10-25% patients will go on to develop diverticulitis within their lifetimes.

Causes

The development of colonic diverticulum is thought to be a result of raised intraluminal colonic pressures. The sigmoid colon has the smallest diameter of any portion of the colon, and therefore it is the portion that is most likely to have the highest intraluminal pressure.

Low dietary fiber, particularly non-soluble fiber, also known as roughage, predisposes individuals to diverticular disease.

Mechanical blockage of a diverticulum, possibly by a piece of feces, may also lead to infection of the diverticulum.

Signs and Symptoms

Most often, patients report of the three classic symptoms - left lower quadrant pain, fever, and leukocytosis, which is an elevation of the white cell count, shown in blood tests. Patients may also complain of nausea or diarrhea, while others may be constipated.

Less commonly, an individual with diverticulitis may experience right-sided abdominal pain. This may be due to the less prevalent right-sided diverticula or a very redundant sigmoid colon.

Diagnosis

The differential diagnosis includes colon cancer, inflammatory bowel disease, ischemic colitis and irritable bowel syndrome, as well as a number of urological and gynecological processes. Some patients report bleeding from the rectum.

Patients presented with such symptoms are commonly studied with a computed tomography or CT scan. The CT scan is very sensitive in diagnosing diverticulitis with about 98% accuracy. It may also identify patients with more complicated diverticulitis, such as those with an associated abscess. CT also allows for radiologically guided drainage of associated abscesses, possibly sparing a patient from immediate surgical intervention.

Other studies, such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.

Treatment

An initial episode of acute diverticulitis is usually treated with conservative medical management, including bowel rest which restricts intake by mouth, IV fluid resuscitation, and broad-spectrum antibiotics, which cover anaerobic bacteria and gram-negative rods. However, recurring acute attacks or complications, such as peritonitis, abscess, or fistula may require surgery, either immediately or on an elective basis.

Upon discharge patients are placed on a high-fiber diet. There is some evidence this lowers the recurrence rate. In some cases surgery may be required.

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