What is Diverticulosis and Diverticulitis?

Diverticulae are outpouchings that occur through weak spots in the wall of the colon (large intestine). Each pouch is known as a diverticulum. The presence of having diverticulae is known as diverticulosis. Diverticulitis refers to inflammation or infection of diverticulae. Diverticulosis becomes more common as we age, found in half or more of people after the age of sixty (60) and to nearly everyone over the age of eighty (80).

What Causes Diverticulosis?

When pressure inside the colon builds up, it can force a bulge in weak areas of the wall of the colon leading to diverticulae. An area of weakness in the wall of the colon can occur where the normal blood vessels penetrate through the bowel wall to supply blood to the inner lining of the colon. Increased pressure in the colon is most commonly caused by constipation. Normally, the muscles in the wall of the colon contract in waves to move waste material. If the material is hard, dry and small, the muscles have to squeeze harder with more force to accomplish movement down the colon. Over time, these forces push out the colon wall, leading to diverticulosis. A diet that is high in meat and fat is often low in fiber - this type of diet also contributes to decreased size, bulk and moisture within the colon.

What Causes Diverticulitis?

When diverticulae become infected or inflamed, diverticulitis develops. The precipitating cause is not always clear but can sometimes be related to certain foods. If a piece of food (for example, a kernel of corn) becomes lodged within the diverticulum, infection or inflammation can result.

What are the Symptoms of Diverticulosis?

The majority of people with diverticulosis have no symptoms. Symptoms that can occur with diverticulosis can include abdominal cramps, bloating and constipation.

What are the Symptoms of Diverticulitis?

Diverticulitis most commonly results in abdominal pain, usually with tenderness in the left lower side of the abdomen. The pain may be accompanied by fever, nausea, fatigue, chills and constipation.

What are the Complications of Diverticulosis?

• Diverticulitis: Diverticulitis can be mild (and treated at home) or more severe requiring hospitalization.

• Bleeding: Diverticulae usually form in areas where there is a blood vessel penetrating through the bowel to supply blood to the inner lining of the colon. If this blood vessel should become inflamed or rupture, bleeding can result. The patient then notes the passage of bright red blood from the rectum or with the stools. This may be accompanied by blood clots. The bleeding can be minimal or extensive - potentially requiring hospitalization and transfusions and, at times, surgery to remove the bleeding area.

• Perforation: When an infected diverticulum (diverticulitis) develops a hole, leakage of bowel contents can occur into the abdomen. Bacteria within the colon can then cause an infection in the abdominal cavity. If the infection forms a pocket of pus, this is known as an abscess. Surgery is usually required to correct these problems.

• Fistula: A fistula is an abnormal connection (tunnel) between two areas. If an area of infection (diverticulitis) is adjacent to another loop of bowel or the urinary bladder or other structures, the infection can burrow a hole between these two areas leading to a communication or a tunnel between them. The most common fistula from diverticulitis is between the sigmoid colon and the urinary bladder. Repeated urinary tract infections then develop and the patient also may note that they pass air or even stool with urine. This problem usually requires surgery to correct.

• Obstruction: The inflammation associated with diverticulitis can lead to scarring which decreases the diameter of the large intestine. With significant scarring, blockage can then result. The symptoms may include abdominal cramps/pain, decreased bowel movements or constipation or if the obstruction is complete (total obstruction) abdominal swelling, distention, nausea and vomiting occur. These complications require surgery.

How is Diverticulosis Diagnosed?

Typical symptoms may lead to a presumptive diagnosis of diverticulosis (constipation, abdominal cramps). However, since most people do not have symptoms of diverticulosis it is often found as part of testing for other reasons. Testing that can be performed to evaluate diverticulosis can include a flexible sigmoidoscopy or a colonoscopy, Barium Enema X-ray examination, or CT scanning of the abdomen.

How is Diverticulitis Diagnosed?

The diagnosis of diverticulitis may be tentatively made if typical symptoms occur such as left lower quadrant pain associated with fever. Testing for diverticulitis may include a CT Scan of the abdomen looking for thickening of the bowel with inflammation around it, or possible abscess, or fistula, or perforation. A lower GI X-ray examination can show diverticulosis and sometimes inflammation (diverticulitis). A fiberoptic examination (flexible sigmoidoscopy or colonoscopy) usually is not done if the person has active severe diverticulitis, but when performed can directly visualize inflammation in and around the diverticulae.

What is the Treatment for Diverticulosis?

A high fiber diet is often helpful to bulk up the stools and thus minimize contraction force required by the colon to move waste materials through. One should attempt to drink plenty of fluids with a high fiber diet. For further details, please see separate article on High Fiber Diet. The daily use of a bulk fiber agent, such as Metamucil, Citrucel, Konsyl, Fibercon (and others) is often very useful to help ensure sufficient regular fiber intake.

What is the Treatment for Diverticulitis?

Initial treatment is aimed at clearing the infection - this often includes antibiotics and dietary restrictions (clear liquid diet which is then advanced to a low residue diet as the diverticulitis improves). Pain medications may be needed during the acute phase. For a moderate or severe episode, hospitalization may be required. Most cases of diverticulitis are treated medically, as described above, but if the condition becomes more severe or recurrent, surgery is then indicated to remove the diseased area of the colon. A high fiber diet should be maintained often with the use of a daily bulk fiber agent. One should attempt to drink plenty of fluids with a high fiber diet.

Surgery for Diverticulosis/Diverticulitis

Although most patients with diverticulosis and diverticulitis are managed medically (without surgery), surgery is often required for patients who develop complications of diverticulitis (as discussed above). Surgery usually involves removing the diseased area that contains diverticulosis/diverticulitis. The two ends of the remaining colon are then sewn back together to maintain continuity of the colon—minus the diseased segment. If there is significant infection or pus or abscess at the time of surgery, a temporary colostomy bag may be needed. After recovery from the infection, the colostomy usually can be reversed and the colon internalized to again restore continuity.