Diverticular disease is a condition increasingly common in older adults, especially in developed countries with low-fiber diets. It includes diverticulosis (the presence of small pouches or diverticula in the colon) and diverticulitis (inflammation or infection of these pouches). While often silent, diverticular disease can lead to serious complications like abscesses, fistulas, and perforation if left untreated.
What is Diverticular Disease?
Diverticular disease refers to a spectrum of conditions affecting the colon:
- Diverticulosis: Formation of diverticula, small sac-like protrusions in the colon lining
- Diverticulitis: Inflammation or infection of diverticula
- Can progress to complications like abscess, fistula, peritonitis, and stricture
Key Points
- Most cases are asymptomatic
- Acute episodes typically resolve with conservative management
- Emergency surgery is reserved for complications or recurrence
- High-fiber diet is essential for prevention
- Diverticular strictures may mimic colon cancer and must be biopsied
Epidemiology
- Male-to-female ratio: 1.5:1
- Most common after age 40
- Over 50% of people aged >60 years in Western countries have diverticulosis
- Higher prevalence in low-fiber diet populations
Causes and Risk Factors
Aetiology
- Increased intraluminal pressure causes mucosal herniation through weak points in the colon wall
- Weak spots are where vasa recta penetrate the muscular layer
- Low-fiber diets
- Aging
- Obesity
- Smoking
- Sedentary lifestyle
- NSAID use
Types of Diverticular Disease
1. Asymptomatic Diverticulosis
- Most common form
- Usually found incidentally on colonoscopy or imaging
2. Symptomatic Uncomplicated Disease
- Abdominal discomfort
- Bloating
- Irregular bowel movements
3. Diverticulitis
- Inflammation of diverticula
- Presents with pain, fever, and tenderness
Clinical Features
Asymptomatic:
- No symptoms, discovered incidentally
Painful Diverticular Disease:
- Left lower abdominal pain (most common)
- Bloating, constipation or diarrhea
Acute Diverticulitis:
- Fever, malaise
- Localized tenderness in left iliac fossa (LIF)
- Palpable mass (in some cases)
- Nausea, vomiting
- Diarrhea or constipation
Complications:
- Perforation → peritonitis
- Fistula: bladder (UTIs), vagina (discharge), small bowel (diarrhea)
- Abscess
- Hemorrhage: painless lower GI bleeding
- Obstruction: chronic inflammation may cause stricture
Diagnostic Investigations
Diverticulosis:
- Colonoscopy or barium enema
- Flexible sigmoidoscopy (less invasive)
Diverticulitis:
- CT scan: best for diverticular mass, abscess, perforation
- Ultrasound: helpful in acute settings
- X-ray: rule out free air in perforation
- Water-soluble contrast enema: for obstruction evaluation
Suspected Complications:
- Fistula: CT, MRI, cystoscopy, colonoscopy
- Bleeding: Colonoscopy, selective angiography
Treatment: Step-by-Step Management
Medical Management
1. Asymptomatic Diverticulosis
- No treatment required
- High-fiber diet, increase fluid intake
- Avoid seeds and nuts is no longer a valid concern
2. Painful Diverticular Disease
- Fiber supplements, antispasmodics
- Laxatives for constipation
3. Acute Diverticulitis
- Antibiotics: e.g., amoxicillin-clavulanate + metronidazole for 7–10 days
- Dietary modification: low-residue diet initially
- Hospital admission: if high fever, immunocompromised, elderly
Surgical Management
Surgery is required for:
- Recurrent diverticulitis
- Complications: perforation, abscess, fistula, stricture
1. Emergency Surgeries:
Hartmann’s Procedure:
- Resection of diseased colon
- Creation of end colostomy
- Used in diffuse peritonitis
Laparoscopic Lavage and Drainage:
- Used for limited peritonitis
2. Elective Surgery:
- Resection with primary anastomosis
- Especially in patients with recurrent episodes or stricture
3. Complicated Surgery:
- Fistula resection
- Colovesical or coloenteric repair
- May include stoma creation
Common Complications
1. Abscess:
- Diagnosed by CT
- Managed with antibiotics ± percutaneous drainage
2. Fistulas:
- Common to bladder, vagina, small intestine
- Requires surgical repair
3. Perforation:
- Leads to purulent or fecal peritonitis
- Requires emergency surgery
4. Strictures:
- May mimic colon cancer
- Often requires resection and histology
- Painless but significant
- Often resolves spontaneously
Prognosis and Hinchey Classification
Diverticular disease is generally benign, but complications can be severe. Prognosis depends on the stage of diverticulitis.
Hinchey Classification of Diverticulitis
| Stage | Description |
|---|---|
| I | Localized abscess (phlegmon) |
| II | Pelvic or retroperitoneal abscess |
| III | Generalized purulent peritonitis |
| IV | Generalized fecal peritonitis |
Stage I-II can often be managed conservatively.
Stage III-IV usually requires emergency surgery.
Prevention Tips
- Eat a high-fiber diet: fruits, vegetables, whole grains
- Drink plenty of water
- Avoid excessive red meat
- Regular exercise
- Maintain healthy weight
- Avoid smoking and NSAIDs
Frequently Asked Questions (FAQs)
Q1: What is the difference between diverticulosis and diverticulitis?
A: Diverticulosis is the presence of pouches. Diverticulitis is inflammation or infection of those pouches.
Q2: Can diverticulitis be cured?
A: Acute episodes can resolve with antibiotics, but surgery may be needed for recurrence or complications.
Q3: How can I prevent flare-ups?
A: Follow a high-fiber diet, stay hydrated, and avoid constipation.
Q4: Is surgery always required?
A: No. Most cases resolve without surgery unless complications arise.
Q5: Can it cause cancer?
A: No, but strictures should always be biopsied to rule out colon cancer.
Final Thoughts
Diverticular disease is common, manageable, and mostly preventable. Recognizing the symptoms early and managing lifestyle can prevent complications. Medical therapy works for most, but surgery plays a key role in managing recurrent or severe disease.
