Many people have small pouches in the lining of the colon, or large
intestine, that bulge outward through weak spots. Each pouch is called
a diverticulum. Multiple pouches are called diverticula. The condition
of having diverticula is called diverticulosis. About 10 percent of
Americans older than 40 have diverticulosis.1 The condition becomes more common as people age. About half of all people older than 60 have diverticulosis.2
Many people have small pouches in their colon
that bulge outward through weak spots. Each pouch is called a
diverticulum. Multiple pouches are called diverticula. The condition of
having diverticula is called diverticulosis.
Diverticula are most common in the lower portion of the large
intestine, called the sigmoid colon. When the pouches become inflamed,
the condition is called diverticulitis. Ten to 25 percent of people
with diverticulosis get diverticulitis.3 Diverticulosis and diverticulitis together are called diverticular disease.
1Bogardus ST. What do we know about diverticular disease? A brief overview. Journal of Clinical Gastroenterology. 2006;40:S108-S111. 2Ibid. 3Ibid.
What are the symptoms of diverticulosis and diverticulitis?
Diverticulosis
Most people with diverticulosis do not have any discomfort or
symptoms. However, some people may experience crampy pain or discomfort
in the lower abdomen, bloating, and constipation. Other conditions such
as irritable bowel syndrome and stomach ulcers cause similar problems,
so the symptoms do not always mean a person has diverticulosis. People
with chronic symptoms should visit their doctor or health care provider.
Diverticulitis
The most common symptom of diverticulitis is abdominal pain. The
most common sign on examination is tenderness in the lower left side of
the abdomen. Usually, the pain is severe and comes on suddenly, but it
can also be mild and become worse over several days. The intensity of
the pain can fluctuate. A person may experience cramping, nausea,
vomiting, fever, chills, or a change in bowel habits.
What are the complications of diverticulitis?
Diverticulitis can lead to bleeding; infections; small tears, called
perforations; or blockages in the colon. These complications always
require treatment to prevent them from progressing
and causing serious illness.
Bleeding
Rectal bleeding from diverticula is a rare complication. Doctors
believe the bleeding is caused by a small blood vessel in a
diverticulum that weakens and then bursts. When diverticula bleed,
blood may appear in the toilet or in the stool. Bleeding can be severe,
but it may stop by itself and not require treatment. A person who has
bleeding from the rectum, even a small amount, should see a doctor right
away. Often, colonoscopy is used to identify the site of bleeding and
stop the bleeding. Sometimes the doctor injects dye into an artery, a
procedure called angiography, to identify and treat diverticular
bleeding. If the bleeding does not stop, surgery may be necessary to
remove the involved portion of the colon.
Abscess, Perforation, and Peritonitis
Diverticulitis may lead to infection, which often clears up after a
few days of treatment with antibiotics. If the infection gets worse, an
abscess may form in the wall of the colon.
An abscess is a localized collection of pus that may cause swelling
and destroy tissue. If the abscess is small and remains in the wall of
the colon, it may clear up after treatment with antibiotics. If the
abscess does not clear up with antibiotics, the doctor may need to
drain it using a catheter, a small tube, placed into the abscess through
the skin. After giving the patient numbing medicine, the doctor inserts
the needle through the skin until reaching the abscess and then drains
the fluid through the catheter. This process may be guided by
sonography or x ray.
Infected diverticula may develop perforations. Sometimes the
perforations leak pus out of the colon and form a large abscess in the
abdominal cavity, a condition called peritonitis. A person with
peritonitis may be extremely ill with nausea, vomiting, fever, and
severe abdominal tenderness. The condition requires immediate surgery
to clean the abdominal cavity and remove the damaged part of the colon.
Without prompt treatment, peritonitis can be fatal.
Fistula
A fistula is an abnormal connection of tissue between two organs or
between an organ and the skin. When damaged tissues come into contact
with each other during infection, they sometimes stick together. If
they heal that way, a fistula may form. When diverticulitis-related
infection spreads outside the colon, the colon's tissue may stick to
nearby tissues. The organs usually involved are the bladder, small
intestine, and skin.
The most common type of fistula occurs between the bladder and the
colon. This type of fistula affects men more often than women. It can
result in a severe, long-lasting infection of the urinary tract. The
problem can be corrected with surgery to remove the fistula and the
affected part of the colon.
Intestinal Obstruction
Scarring caused by infection may lead to partial or total blockage
of the intestine, called intestinal obstruction. When the intestine is
blocked, the colon is unable to move bowel contents normally. If the
intestine is completely blocked, emergency surgery is necessary.
Partial blockage is not an emergency, so the surgery to correct it can
be planned.
What causes diverticular disease?
Although not proven, the dominant theory is that a low-fiber diet
causes diverticular disease. The disease was first noticed in the
United States in the early 1900s, around the time processed foods were
introduced into the American diet. Consumption of processed foods
greatly reduced Americans' fiber intake.
Diverticular disease is common in developed or industrialized
countries, particularly the United States, England, and Australia, where
low-fiber diets are consumed. The disease is rare in Asia and Africa,
where most people eat high-fiber diets.
Fiber is the part of fruits, vegetables, and grains that the body
cannot digest. Some fiber, called soluble fiber, dissolves easily in
water. It takes on a soft, jelly-like texture in the intestines.
Insoluble fiber passes almost unchanged through the intestines. Both
kinds of fiber help prevent constipation by making stools soft and easy
to pass.
Constipation, or hard stool, may cause people to strain when passing
stool during a bowel movement. Straining may cause increased pressure
in the colon, which may cause the colon lining to bulge out through
weak spots in the colon wall. These bulges are diverticula.
Lack of exercise also may be associated with a greater risk of
forming diverticula, although the reasons for this are not well
understood.
Doctors are not certain what causes diverticula to become inflamed.
The inflammation may begin when bacteria or stool are caught in the
diverticula. An attack of diverticulitis can develop suddenly and
without warning.
How is diverticular disease diagnosed?
To diagnose diverticular disease, the doctor asks about medical
history, does a physical exam, and may perform one or more diagnostic
tests. Because most people do not have symptoms, diverticulosis is
often found through tests ordered for another ailment. For example,
diverticulosis is often found during a colonoscopy done to screen for
cancer or polyps or to evaluate complaints of pain or rectal bleeding.
When taking a medical history, the doctor may ask about bowel
habits, pain, other symptoms, diet, and medications. The physical exam
usually involves a digital rectal exam. To perform this test, the
doctor inserts a gloved, lubricated finger into the rectum to detect
tenderness, blockage, or blood. The doctor may check stool for signs of
bleeding and test blood for signs of infection. If diverticulitis is
suspected, the doctor may order one of the following radiologic tests:
Abdominal ultrasound. Sound waves are
sent toward the colon through a handheld device that a technician
glides over the abdomen. The sound waves bounce off the colon and other
organs, and their echoes make electrical impulses that create a
picture, called a sonogram, on a video monitor. If the diverticula are
inflamed, the sound waves will also bounce off of them, showing their
location.
Computerized tomography (CT) scan.
The CT scan is a noninvasive x ray that produces cross-section images
of the body. The doctor may inject dye into a vein and the person may
be given a similar mixture to swallow. The person lies on a table that
slides into a donut-shaped machine. The dye helps to show complications
of diverticulitis such as perforations and abscesses.
How is diverticular disease treated?
A high-fiber diet and pain medications help relieve symptoms in most
cases of diverticulosis. Uncomplicated diverticulitis with mild
symptoms usually requires the person to rest, take oral antibiotics,
and be on a liquid diet for a period of time. Sometimes an attack of
diverticulitis is serious enough to require a hospital stay,
intravenous (IV) antibiotics, and possibly surgery.
Diverticulosis
Increasing the amount of fiber in the diet may reduce symptoms of
diverticulosis and prevent complications such as diverticulitis. Fiber
keeps stool soft and lowers pressure inside the colon so that bowel
contents can move through easily. The American Dietetic Association
recommends consuming 20 to 35 grams of fiber each day. The table "What
foods have fiber?" shows the amount of fiber in some foods that a
person can easily add to the diet.
The doctor may also recommend taking a fiber product such as
methylcellulose (Citrucel) or psyllium (Metamucil) one to three times a
day. These products are available in powder, pills, or wafers, and
provide 2 to 3.5 grams of fiber per dose. Fiber products
should be taken with at least 8 ounces of water.
Avoidance of nuts, popcorn, and sunflower, pumpkin, caraway, and
sesame seeds has been recommended by physicians out of fear that food
particles could enter, block, or irritate the diverticula. However, no
scientific data support this treatment measure. Eating
a high-fiber diet is the only requirement highly emphasized across the
medical literature. Eliminating specific foods is not necessary. The
seeds in tomatoes, zucchini, cucumbers, strawberries, and raspberries,
as well as poppy seeds, are generally considered harmless. People
differ in the amounts and types of foods they can eat. Decisions about
diet should be made based on what works best for each person. Keeping a
food diary may help identify what foods may cause symptoms.
If cramps, bloating, and constipation are problems, the doctor may
prescribe a short course of pain medication. However, some pain
medications actually cause constipation.
Diverticulitis
Treatment for diverticulitis focuses on clearing up the inflammation
and infection, resting the colon, and preventing or minimizing
complications.
Depending on the severity of symptoms, the doctor may recommend bed
rest, oral antibiotics, a pain reliever, and a liquid diet. If symptoms
ease after a few days, the doctor will recommend gradually increasing
the amount of high-fiber foods in the diet.
Severe cases of diverticulitis with acute pain and complications
will likely require a hospital stay. Most cases of severe
diverticulitis are treated with IV antibiotics and a few days without
food or drink to help the colon rest. In some cases, surgery may be
necessary.
What foods have fiber? Examples of foods that have fiber include
Breads, cereals, and beansFiber
1/2 cup of navy beans9.5 grams
1/2 cup of kidney beans8.2 grams
1/2 cup of black beans7.5 grams
Whole-grain cereal, cold
1/2 cup of All-Bran9.6 grams
3/4 cup of Total2.4 grams
3/4 cup of Post Bran Flakes5.3 grams
1 packet of whole-grain cereal, hot3.0 grams
(oatmeal, Wheatena)
1 whole-wheat English muffin4.4 grams
Fruits
1 medium apple, with skin3.3 grams
1 medium pear, with skin4.3 grams
1/2 cup of raspberries4.0 grams
1/2 cup of stewed prunes3.8 grams
Vegetables
1/2 cup of winter squash2.9 grams
1 medium sweet potato with skin4.8 grams
1/2 cup of green peas4.4 grams
1 medium potato with skin3.8 grams
1/2 cup of mixed vegetables4.0 grams
1 cup of cauliflower2.5 grams
1/2 cup of spinach3.5 grams
1/2 cup of turnip greens2.5 grams
Source: U.S. Department of Agriculture and U.S. Department of Health and Human Services, Dietary Guidelines for Americans, 2005
When is surgery necessary for diverticulitis?
If symptoms of diverticulitis are frequent, or the patient does not
respond to antibiotics and resting the colon, the doctor may advise
surgery. The surgeon removes the affected part of the colon and joins
the remaining sections. This type of surgery, called colon
resection, aims to prevent complications and future diverticulitis. The
doctor may also recommend surgery for complications
such as a fistula or partial intestinal obstruction.
Immediate surgery may be necessary when the patient has other
complications, such as perforation, a large abscess, peritonitis,
complete intestinal obstruction, or severe bleeding. In these cases,
two surgeries may be needed because it is not safe to rejoin the colon
right away. During the first surgery, the surgeon cleans the infected
abdominal cavity, removes the portion of the affected colon, and
performs a temporary colostomy, creating an opening, or stoma, in the
abdomen. The end of the colon is connected to the opening to allow
normal eating while healing occurs. Stool is collected in a pouch
attached to the stoma. In the second surgery several months later, the
surgeon rejoins the ends of the colon and closes the stoma.
Points to Remember
Diverticulosis occurs when small pouches called diverticula bulge outward through weak spots in the colon, or large intestine.
Most people with diverticulosis never have any discomfort or symptoms.
Diverticula form when pressure builds inside the colon wall, usually because of constipation.
The most likely cause of diverticulosis is a low-fiber diet because it increases constipation and pressure inside the colon.
For most people with diverticulosis, eating a high-fiber diet is the only treatment needed.
Fiber
intake can be increased by eating whole-grain breads and cereals;
fruits like apples and pears; vegetables like peas, spinach, and
squash; and starchy vegetables like kidney and black beans.
Diverticulitis occurs when the pouches become inflamed and cause pain and tenderness in the lower left side of the abdomen.
Diverticulitis
can lead to bleeding; infections; small tears, called perforations; or
blockages in the colon. These complications always require treatment to
prevent them from progressing and causing serious illness.
Severe
cases of diverticulitis with acute pain and complications will likely
require a hospital stay. When a person has complications or does not
respond to medication, surgery may be necessary.
Reprinted from National Digestive Diseases Information Clearinghouse.
