Diverticular Disease of the Colon

What is Diverticulosis?

A diverticulum is an out-pouching of the mucosa (the inner lining layer) through the muscular layer of the gastrointestinal tract wall. Think of it as a small hernia. Diverticula may occur anywhere in the GI tract, but they occur more commonly in the colon. In general, when the word diverticulosis is mentioned, it refers to colonic diverticulosis.

The mucosa is pushed through a weak spot at the muscle layer forming a diverticulum

Colonoscopic appearance of diverticula

How common is Diverticulosis?

Diverticulosis is a common disorder especially in older people. The condition is rarely seen in people under the age of 30 and is most common in those over 60. Both men and women are equally affected. Diverticula are more common in the left side of the colon (the sigmoid colon and the descending colon). In Asians and in African Americans, they may occur more commonly in the right side of the colon (the cecum and the ascending colon).

What causes Diverticulosis?

We do not know for certain why diverticula develop. A low fiber diet is felt to be the most likely cause of diverticulosis. In Africa where the diet is rich in fiber, diverticulosis is rare. A high fiber diet is thought to decrease the intra-colonic pressure thus minimizing the risk of developing diverticulosis. There also appears to be a genetic predisposition to diverticulosis, that is, if you have a family history of diverticulosis you may develop it as well.

What are the symptoms of diverticulosis?

The majority of persons with diverticulosis do not develop any symptoms.  The condition is usually discovered incidentally during a routine screening colonoscopy, a barium enema examination or during a CT scan of the abdomen and pelvis.

Some patients may have mild, intermittent abdominal pain, bloating, flatulence, and altered bowel habits. However, coexistence of irritable bowel syndrome (IBS) is possible and that may offer an explanation to such symptoms.

Are there any complications to diverticulosis?

The two most common complications of diverticulosis are diverticulitis and diverticular bleeding.

1. Diverticulitis

Diverticulitis is an inflammation or an infection of one or more of the diverticula. Persons who suffer from this condition usually complain of abdominal pain at the site of the diverticula (usually at the left lower abdomen), fever, chills, nausea and vomiting. Mild cases may be treated by oral antibiotics on outpatient basis. More severe cases may require admission to a hospital and treatment with intravenous antibiotics. Persons who suffer from recurrent episodes of diverticulitis may require surgical resection of the inflamed part of the colon.

Rarely, a fistula may develop as a complication of diverticulitis. A fistula is a tract or a passage that has formed between the colon and another organ in the body, or between the colon and the skin. Examples are: colo-vesical fistula (a fistula between the colon and the urinary bladder), a colo-vaginal fistula (between the colon and the vagina), a colo-colonic fistula (between 2 segments of the colon), and colo-cutaneous fistula (between the colon and the skin). Once a fistula develops, surgical treatment is usually indicated.

2. Diverticular Bleeding

Diverticular hemorrhage is the most common cause of acute massive colonic blood loss. Massive bleeding from colonic diverticula occurs in 5% of patients; minor bleeding occurs in up to 47%. Half of diverticular hemorrhages arise from a diverticulum at the right side of the colon.

A diverticulum may erode into the wall of a blood vessel, causing bleeding

Diverticular bleeding is characterized by the sudden, painless passage of large amounts of bright-red blood from the rectum and may be associated with low blood pressure, tachycardia (a rapid heartbeat), or syncope. In approximately 80% of cases bleeding stops spontaneously. The patient is usually treated conservatively with intravenous fluids and may have to receive blood transfusion. A colonoscopy is usually performed to rule out other causes of bleeding and to help localize the site of bleeding.  If bleeding persists a mesenteric angiogram may be performed to localize the site of bleeding and, in some cases, stop it by embolization (blocking off the bleeding artery). Surgical resection of the bleeding site may be indicated if all other measures fail in stopping the blood loss.

Can Diverticulosis be prevented?

It is not know whether or not diverticulosis could be prevented. A high fiber diet (bran cereals, whole wheat bread, fresh fruits and leafy vegetables) may help decrease the risk of developing diverticulosis. Once present, diverticulosis cannot be eliminated; however, fiber-rich diets may help minimize the risk of complications.

Seeds or no seeds?

The commonly offered advice to avoid “seeds” as they may get lodged in one of the diverticula and cause problems is not supported by any study. Moreover, we have seen thousands of diverticula during colonoscopy examinations without seeing any seed in any of the diverticula.
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