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Diverticulosis & Diverticulitis

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Dr. Minocha  is a practicing gastroenterologist and author of "Natural Stomach Care: Treating and Preventing Digestive Disorders with Best of Eastern and Western Therapies"


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A diverticulum is a pouch or a pocket-like opening in the bowel wall, usually in the colon. The pouch is formed by the hernia of superficial layers of the colon through the weak points in the bowel wall. High fiber diet appears to protect against formation of such pouches.

Diverticulitis or Diverticulosis :    The occurrence of a diverticulum is known as diverticulosis. When a diverticulum becomes inflamed, the condition is known as diverticulitis. We frequently hear the phrase "I have diverticulitis". Generally, these patients are actually referring to diverticulosis and not diverticulitis. Diverticulosis is usually discovered incidentally during a barium x ray or lower GI scope exam. In fact, the majority of people will never be aware that they have this condition.

Prevalence : Diverticulosis was uncommon (5-10% population) at the beginning of the 20th century. One century later, the prevalence is 5% at the age of 40 years, 30% by 60 years and an overwhelming majority have it after the age of 85 years. It is mostly a disease of the affluent western society. In contrast, the prevalence in Asia and Africa is less than one percent. The difference in geographic distribution is attributed to differences in dietary fiber intake.

Painful Diverticular Disease : Although the diverticula are usually harmless and do not cause problems in 70-80% of the patients, some persons may develop cramps, bloating, and irregular bowel movements without fever or other signs of infection. These patients are believed to have "painful diverticular disease". Although a cause-effect relationship between these symptoms and diverticulosis has not been established, these patients are usually treated with high fiber diet plus medications to relieve spasms. Some of these patients may not respond to medical therapy. Use of surgery in such patients in the absence of giant diverticula and or any of its complications is controversial.  

Diverticulitis : In about 25% of patients with painful diverticular disease, a small sized hole develops in the bowel wall through the diverticulum leading to infection and inflammation around the colon. This complication is known as diverticulitis. The infection usually stays localized, but can spread into the abdomen causing severe diverticulitis. Senior citizens are prone to the more serious form, especially if they are taking medications that increase susceptibility to infection. Patients develop pain in the lower, left part of the abdomen, along with fever and other signs of infection. A majority of patients report nausea, vomiting, distended abdomen or recent "constipation". Acute inflammation in the colon may also affect adjacent organs like the bladder, causing painful or increased urination.

Diagnosis of diverticulitis is usually based on clinical history and physical examination. X rays are taken to exclude other causes of abdominal pain like appendicitis, abscess in the abdomen or inflamed colon, which may mimic an acute diverticulitis. A CT scan of the abdomen is helpful in atypical cases. A colonoscopy (lower GI scope test) is generally not advisable during an acute episode.

Treatment of mild diverticulitis includes liquid diet and oral antibiotics. Hospitalization and intravenous medications are needed in severe cases. Most patients respond to medical treatment within 2-3 days. However, antibiotics are continued for 10-14 days. Colonoscopy is performed a few weeks after the resolution of an acute episode of diverticulitis to exclude any cancer that may be present in as many as 10% of these cases.

The need for surgery during an acute episode of diverticulitis is rare, but may be required for patients who fail to improve with medical therapy. Diverticulitis recurs in 25% of cases after the first episode and in 50% of cases after the second episode. Surgery is indicated in such patients.

 

Complications of diverticulitis include abscess in the abdomen, blockage of the colon as well as fistula between the colon and the bladder or female organs. Treatment of these complications generally involves removal of the affected portion of colon.

Diverticular Hemorrhage:Bleeding may occur from the diverticulum in 5% of patients. It is usually sudden in onset, painless and substantial. Diverticulosis is the cause in 30 to 50 percent of cases with massive bleeding from the colon. However, the bleeding stops spontaneously in most patients. In some cases, the bleeding may continue intermittently for a few hours to a few days before resolving. Chronic intermittent bleeding due to diverticulosis is unusual. Blood transfusions are required in less than 5% of these cases. Some people believe that the diverticula bleed when they are inflamed. Actually, it is quite the opposite. Bleeding is usually not seen during an acute episode of acute diverticulitis. Diverticula bleed when they are otherwise healthy.

Diagnostic strategy in cases of rectal bleeding is directed at localizing the site and the cause since there are no clinical features to reliably distinguish diverticular bleeding from other causes of gastrointestinal hemorrhage. Various combinations of tests including a colonoscopy, bleeding scan and angiogram of the colon (just like cardiac cath) are used depending upon the clinical situation. Treatment includes intravenous fluids and blood products, plus attempts to stop bleeding if it persists. As many as 80% patients do not have any recurrence of bleeding. Surgery may be needed in 50% of cases of massive diverticular bleeding.

Role of diet in preventing complications: Until a few decades ago, dietary restrictions were practiced in patients with asymptomatic diverticulosis in order to prevent diverticulitis and diverticular bleeding. "Irritating food" such as grape skin, corn and seeds were avoided. We now know that problems due to diverticulosis occur infrequently regardless of the type of food ingested. As such, most physicians prescribe a high fiber diet without insisting on any dietary restrictions.

In summary, diverticulosis is a very common, and usually a very benign condition. Complications occur only in a minority of patients, and most of them get well with medical treatment alone without any need for surgery.

Anil Minocha M.D.; FACP; FACG

 

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