Diverticulosis & Diverticulitis Victor Politi, M.D., FACP, FACEP Medical Director St. John’s University, School of Allied Health Physician Assistant Program

The occurrence of a diverticulum is known as diverticulosis Diverticulum – 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 a small pouch in the colon that bulges outward through a weak spot The occurrence of a diverticulum is known as diverticulosis

Normal Abnormal

When the pouches become infected or inflamed, the condition is called diverticulitis. This happens in 10 to 25 percent of people with diverticulosis. Diverticulosis and diverticulitis are also called diverticular disease

Diverticulitis can occur anywhere in the gastrointestinal tract most commonly observed in the colon. Small bowel diverticulitis is far less common than colonic diverticulitis. Asymptomatic diverticulosis is a common condition, but few patients with diverticula develop symptomatic diverticulitis.

In about 25% of patients with painful diverticular disease - 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.

Predisposing Factors Aging Colonic motility disorders causes changes in collagen structure- may lead to weakening of the colonic wall. Colonic motility disorders Long term Corticosteroid or NSAID use Genetics believed to play a role, Asian people tend to have a predominance of right-sided diverticula, while Western people tend to have left-sided disease

Diverticulitis Symptoms Most common symptom -abdominal pain Most common sign- tenderness around the left side of the lower abdomen If infection is the cause, fever, nausea, vomiting, chills, cramping, and constipation may occur as well. The severity of symptoms depends on the extent of the infection and complications

Diverticulitis Complications Diverticulitis can lead to Abscess Diverticular Hemorrhage Intestinal fistula Intestinal perforation Intestinal obstruction Sepsis and septic shock

Diverticulitis Complications Infection Treated with antibiotics usually clears up after a few days of treatment Rest the Gut Abscess - An abscess is an infected area with pus that may cause swelling and destroy tissue

Diverticulitis Complications Perforation- Sometimes the infected diverticula may develop small holes (perforations) The perforations allow pus to leak out of the colon into the abdominal area If the abscess is small and remains in the colon, it may clear up after treatment with antibiotics. If the abscess does not clear up with antibiotics, it may require drainage (percutaneous catheter drainage) Sometimes surgery is needed to clean the abscess and, if necessary, remove part of the colon

Diverticulitis Complications Peritonitis- (an infection of the abdominal cavity) A large abscess can become a serious problem if the infection leaks out and contaminates areas outside the colon. Infection that spreads into the abdominal cavity is called peritonitis. Peritonitis requires immediate surgery to clean the abdominal cavity and remove the damaged part of the colon. Without surgery, peritonitis can be fatal.

Diverticulitis Complications Fistula- 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 forms 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.

Diverticulitis Complications Fistula The most common type of fistula occurs between the bladder and the colon. Colovesicular fistula (colon to urinary bladder). This is observed almost exclusively in men Also seen in women following hysterectomy This type of fistula can result in a severe, long-lasting infection of the urinary tract. Can be corrected with surgery to remove the fistula and the affected part of the colon Colovaginal and colocutaneous fistulae are much less common

Diverticulitis Complications Intestinal Obstruction The scarring caused by infection may cause partial or total blockage of the large intestine. When this happens, the colon is unable to move bowel contents normally. If the obstruction totally blocks the intestine, emergency surgery is necessary

History/Physical The clinical presentation of diverticulitis depends on: location severity of the underlying inflammatory process and on whether complications are present

Imaging Studies X-rays to make sure the colon has not perforated CT scan with contrast of the abdomen/pelvis if the diagnosis is unclear Flexible Sigmoidoscopy and Barium enema only after symptoms are improved (if these tests are done too early, they can cause a colon perforation)

Imaging Studies CT scan of the abdomen is considered the optimal method of investigation in patients suspected of acute diverticulitis. CT scan is also very helpful in determining the extent of complications of the disease

Procedures Endoscopy is not usually used in the evaluation of acute episodes of diverticulitis because of the possibility of perforation and subsequent development of peritonitis

Treatment of diverticulitis Treatment for diverticulitis focuses on: clearing up the infection and inflammation resting the colon (bed rest,liquid diet, pain meds as needed) preventing or minimizing complications An attack of diverticulitis without complications may respond to antibiotics within a few days if treated early.

Treatment of diverticulitis Hospitalization is required if: patients are unable to tolerate oral hydration if outpatient therapy fails if notable fever and/or peritoneal signs develop if pain is severe enough to require narcotic analgesia or if patients have a chronic underlying medical condition.

Treatment of diverticulitis Surgical treatment is usually necessary in only 20-30% of patients with acute diverticulitis

Dietary Management Administer nothing by mouth in episodes of moderate-to-severe acute diverticulitis. In mild episodes, a clear liquid diet is advised. Long-term management includes a high-fiber, low-fat, and low-beef diet.

Dietary Management 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 20 to 35 grams of fiber each day.

Dietary Management Fiber product – Citrucel or Metamucil once a day. These products are mixed with water and provide about 2 to 3.5 grams of fiber per tablespoon, mixed with 8 ounces of water.

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