Diverticular disease occurs in about 5% of the Western adult population who are younger than forty years of age, but it rises sharply to occur in at least 50% of those who are older than sixty years of age. It’s a disease most prevalent in the elderly; 65% of those who are older than eighty-five years of age have diverticulosis.
The number of diverticula in the gut can vary from a single occurrence (diverticulum) to hundreds. Generally, diverticula increase in number and in size over time. They are characteristically 0.5-1 cm (0.2-0.4″) in diameter but can exceed 2 cm (0.8″). Although rare, physicians have reported some extreme cases of large diverticula, spanning up to 25 cm (10″).
There is a wide geographic variability of diverticular disease and a striking correlation with an urban diet, which suggests a dietary factor as its root. However, the exact cause of this disease remains unknown. One theory is that diverticula occur when pressure, such as that caused by straining during constipation, builds up inside the colon and makes the intestinal wall balloon out in spots where the wall is weak. These weak spots are the sites between the muscle bundles, which run both lengthwise and circularly throughout the colon. In addition, the bowel tends to become irritable and spastic when there is inadequate bulk passing through and it must contract more intensely to pass contents along.
In about 10-25% of diverticular disease patients, the diverticula become inflamed (diverticulitis).
Symptoms of Diverticular Disease
Please pay close attention to the use of the similar but distinctly different definitions: the condition of diverticular disease (diverticulosis) and inflammation of the diverticula (diverticulitis).
Diverticulosis is often present without any symptoms. Many symptoms are similar to those of irritable bowel syndrome (IBS) and often include changing bowel activities such as constipation, diarrhea, or alternating between the two extreme stool consistencies.
Diverticulitis (flare-up) occurs when the diverticula become inflamed and/or infected. There might be an increase in diarrhea, cramping, and bowel irritability, and symptoms can include intense pain, abdominal cramping, bleeding, bloating, and fever. The pain and tenderness is often in the left lower portion of the abdomen.
Rarely, fistulae, bowel obstruction, and lower intestinal hemorrhage occur, or a diverticulum can perforate, causing a local abscess with a marked increase in the degree and nature of the pain. Additional symptoms are likely to include fever, nausea, and vomiting. Sometimes these complications require urgent surgery.
Diagnosing Diverticular Disease
The presence of colonic diverticula is challenging to diagnose as most patients are asymptomatic and the nonspecific symptoms overlap considerably with those of IBS. Your symptom history and a careful physical examination can reveal important clues to your physician. It is easier to diagnose this condition during a flare-up, as this typically presents with a fever, more tenderness over the abdomen, and more severe symptoms.
Blood tests may reveal the degree of inflammation present and a number of other tests can help pinpoint a diagnosis. X-rays can be helpful to observe the shape and function of the colon. For this test, you undergo a barium-containing enema, which shows up as bright white on X-rays, providing a contrasting picture of the contours of the bowel. Another method is by colonoscopy examination, during which a physician inserts an instrument called a colonoscope via the anus to view the inside of the colon. The scope is made of a hollow, flexible tube with a tiny light and video camera.
Colonoscopies usually require conscious sedation; however, since most diverticula form in the sigmoid colon, your physician might suggest a flexible sigmoidoscopy examination instead. This is a less invasive procedure during which the physician looks at only the lower portion of the bowel, and sedation is not typically required. During periods of flare-up, the bowel might be too tender to perform these investigations and the risk of bowel perforation might be too high, so a physician might choose a computed tomography (CT) scan or an even less invasive procedure known as virtual colonoscopy (VC) during diverticulitis. All imaging tests for the colon require some advance bowel preparation.
Your physician will also consider other conditions that could be causing your symptoms and will eliminate these as possibilities before confirming a diverticular disease diagnosis.
Management of Diverticulosis
Recommendations for the ongoing dietary management of diverticular disease include consuming well-balanced meals and snacks, and ensuring high-fibre content and adequate fluid intake, as outlined in Canada’s Food Guide. Fibre and fluid help soften stool, allowing it to move more quickly and easily through the colon, thereby avoiding excessive pressure against the colon wall.
Aim for 20-35 g of fibre daily, consumed evenly throughout the day. To help monitor your fibre intake, check the nutrient content on the labels of packaged foods. In the Nutrition Facts table, you will find fibre listed in grams (g) and the percentage (%) of the recommended Daily Value (DV) per serving. When the content has less than 5%, the product has a low-fibre content; when the content has 15% or greater, the product has a high-fibre content.
Make gradual changes while increasing fibre intake, as this approach will help avoid bloating, gas, and general abdominal discomfort that can occur as your body adapts to the dietary modifications. Be sure to increase the amount of liquid you drink, especially when increasing fibre.
There is no evidence that excluding whole pieces of fibre from the diet, such as nuts, corn, and seeds, will benefit the disease course, so there is no reason to avoid your favourite high-fibre foods, even if they contain small seeds. Ask us for information regarding a high-fibre diet or consult a registered dietitian in your area, or check our website.
Antispasmodic medication may provide bowel symptom relief; however, this could be treating co-existing irritable bowel syndrome rather than the diverticular disease itself.
Management of Diverticulitis
When a flare-up (diverticulitis) occurs, your physician will most likely recommend an immediate transition to a restricted-fibre or fluid diet and physical rest, and is likely to prescribe antibiotics, possibly antispasmodics, and pain medications. In severe cases, your physician might recommend hospital admission for intravenous feeding so that your bowel may rest for a few days.
Diverticulitis may respond to medical management, but if episodes become frequent, then surgical resection of the affected area might be necessary. Only about 1% of those with diverticular disease require surgery. In many cases, the surgeon can remove the damaged portion of the bowel (colectomy) and connect the remaining ends together. If this is not safe or possible, the surgeon may bring the end of the colon to a new surgical opening through the abdominal wall (colostomy). The patient then wears a removable appliance to collect the bowel contents. A colostomy might be required temporarily or permanently, depending upon the particular circumstances.
Diverticular Disease Outlook
Once a diverticulum forms, it does not go away on its own. The best preventative measure to avoid diverticular disease would seem to be a well-balanced, high-fibre diet beginning as early on in life as possible. There are many other health benefits associated with this diet. By also drinking adequate fluids, and staying physically active, you might be able to prevent further diverticula from forming and avoid unpleasant flare-ups. Many individuals are able to live symptom-free with diverticular disease by making these lifestyle changes. Medical and surgical treatments are available for those whose disease is persistent and unresponsive to these modifications.
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If you have diverticulosis, you know how debilitating diverticulitis flare-ups can be. To prevent these, your doctor may suggest that you eat more fiber, drink plenty of fluids, and exercise regularly. When lifestyle changes aren't enough, you have other options to getting you back on the road to health. Learn more about diverticulum, what the symptoms are, your surgical options and more. Diverticulosis is the medical name for the presence of diverticulum, or small pouches formed in the colon wall. The cause for development of these is not well understood. It is possible the development is a side effect of having too low amount of fiber in your diet. Without fiber to add bulk to the stool, the colon has to work harder than normal to push the stool forward. The pressure from this may cause pouches to form in weak spots along the colon. There also seems to be a genetic component, so it can run in families. When the diverticulum are present but not causing problems, we call it Diverticulosis. We find diverticulum when we conduct a test for other reasons, like a colonoscopy or barium enema. Many people with diverticulosis have no symptoms. They will remain symptom free for the rest of their lives. Diverticulitis happens when the diverticulum become inflamed. Particles of stool or undigested food become stuck in these pouches. This creates both inflammation and infection in the wall of the colon. The infection is due in part to the bacteria that naturally live in the colon. The inflammation causes increased pressure in the diverticulum and discomfort for you. In severe cases, the pressure can cause the diverticulum to burst. Then stool and bacteria flood your lower abdomen causing a severe wide-spread infection. The symptoms of diverticulitis depend upon the degree of inflammation and infection present. Symptoms can include: You should seek medical attention if you have any of these symptoms. Diverticulitis can progress into a severe, wide-spread infection if left untreated. Your doctor will assess your symptoms and do an examination of your abdomen, as well as the rest of your body. You will need tests to determine if you have diverticulitis. Simple diverticulitis accounts for 75 percent of cases. Treatments take place at home using antibiotics and lifestyle changes. Complicated diverticulitis is more severe and accounts for 25 percent of cases. In most cases, you will need hospitalization and surgery. Complications associated with diverticulitis can include the following: Treatment of diverticulitis depends upon how severe your symptoms and disease are. People with diverticulosis who do not have symptoms do not need treatment. Patients with mild, uncomplicated diverticulitis may manage at home by:
If you have a mild form of this disease, you might get better with this alone. But you might need antibiotics for your treatment. In some cases, your infection will return when you stop the antibiotics.
A small percentage of patients will continue to their disease progress, despite proper treatment. To find relief, you may need hospitalization and more aggressive treatment.
If you are being treated for diverticulitis and you develop one or more of the following signs or symptoms, seek immediate medical attention:
What is diverticulitis?
Diverticulum
Symptoms of diverticulitis
Testing for diverticulitis
Complications associated with diverticulitis
Treatment for diverticulitis
- Temperature >100.1ºF (38ºC)
- Worsening or severe abdominal pain
- An inability to tolerate fluids by mouth
If you have moderate to severe symptoms, with any of the below complications, you will likely need hospitalization for more aggressive treatment.
- Temperature >100.1ºF (38ºC)
- Worsening or severe abdominal pain
- An inability to tolerate fluids by mouth
During this time, you will not allowed to eat or drink. This allows the colon to rest and heal. We deliver antibiotics, fluids or needed medications through an IV (intravenous) line.
Other treatments depend on the degree of infection you have. We determine your infection degree through:
- Blood testing
- CT scan, or other imaging studies
- Physical examination
If you have an abscess, we attempt to drain it without major surgery. This quick procedure is done under radiology guidance. A small needle and a drainage tube are placed in the abscess to remove and test the infected fluid.
If you have an obstruction in the colon, you will most likely need surgery. During surgery we remove the inflamed segment of colon and unblock it. This relieves the intestines and you can again pass your stool.
You will almost always need emergency surgery if you have either:
- Peritonitis or an infection in the abdominal cavity
- Sepsis or a severe and wide-spread infection due to a hole in the colon wall
In either case, we remove the perforated part of your colon. Then our care experts clean the infection from your abdominal cavity.
If you develop an abdominal infection, you will usually need emergency surgery.
The surgery removes the diseased and ruptured part of the colon. A two-part surgery may be necessary in some cases.
The first surgery involves removal of the diseased colon and creation of a colostomy. A colostomy is an opening in the skin, where the end of the colon is brought out to the outside. You attach a bag on this end to collect the stool (bowel movements) from the intestine. The lower end of the colon is temporarily sewed closed to allow it to heal.
Connecting the ends immediately is unsafe. Connecting them would put that new junction at very high risk of breaking down.
Instead, we allow the colon inflammation to recede and the infection to go away. Approximately three to six months later, we perform a second surgery. This time we reconnect the two parts of the colon and close the opening in the skin. You are then able to empty your bowels through the rectum.
In some non-emergency situations, we remove the diseased area of the colon. Then we reconnect the two ends of the colon in one surgery, without the need for a colostomy.
Click here for more information about colectomy.
Delayed surgery
If you have a complicated form of diverticulitis, you may need a delayed surgery care plan. First, we try to treat the infection and inflammation with antibiotics and bowel rest. Your doctor reserves surgery for only true emergencies, like peritionitis and sepsis.
If your condition permits, we treat you with antibiotics for several weeks, sometimes 6-8 weeks. Then you get surgery to remove the diseased part of the colon several months later. The chance of recurrence is high if you decide not to have surgery).
Waiting before having surgery allows inflammation and infection to heal. Your surgeon will do a 1-stage surgery where he or she removes the diseased part of the colon and reconnect the colon at the same time. Most patients prefer this over the 2-stage surgery with the colostomy.
Your doctor will discuss all known risks and benefits of surgery versus medical management alone.
In many cases of complicated diverticulitis, the doctor will try to treat the infection and inflammation with antibiotics and bowel rest, and try to reserve surgery for only true emergencies (such as with peritionitis and sepsis). If this is possible, you may be treated with antibiotics for several weeks (sometimes 6-8 weeks), and then surgery to remove the diseased part of the colon will be planned within several months (the chance of recurrence is high if surgery is not done). This allows the inflammation and infection to heal, and will allow the surgeon to do a 1-stage surgery (remove the diseased part of the colon and reconnect the colon at the same time) rather than a 2-stage surgery with the colostomy.
Your doctor will discuss with you the risks and benefits of surgery versus medical management alone.
At the end of a diverticulitis episode, you should have the entire length of your colon examined. We usually perform this exam with a colonoscopy. This colon exam gives us the opportunity to determine the extent of your disease. We also can rule out the presence of abnormal lesions such as polyps or cancer.
In rare cases, people can present with what appears to be diverticulitis, but can turn out to be colon cancer.