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Also called: Diverticular disease

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Diverticula are small pouches that bulge outward through the colon, or large intestine. If you have these pouches, you have a condition called diverticulosis. It becomes more common as people age. About half of all people over age 60 have it. Doctors believe the main cause is a low-fiber diet.

Most people with diverticulosis don’t have symptoms. Sometimes it causes mild cramps, bloating or constipation. Diverticulosis is often found through tests ordered for something else. For example, it is often found during a colonoscopy to screen for cancer. A high-fiber diet and mild pain reliever will often relieve symptoms.

If the pouches become inflamed or infected, you have a condition called diverticulitis. The most common symptom is abdominal pain, usually on the left side. You may also have fever, nausea, vomiting, chills, cramping, and constipation. In serious cases, diverticulitis can lead to bleeding, tears, or blockages. Your doctor will do a physical exam and imaging tests to diagnose it. Treatment may include antibiotics, pain relievers, and a liquid diet. A serious case may require a hospital stay or surgery.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

• Diverticular Disease

  (American Academy of Family Physicians)

  Also in Spanish

• Diverticular Disease

  (National Institute of Diabetes and Digestive and Kidney Diseases)

  Also in Spanish

• Diverticulitis

  (Mayo Foundation for Medical Education and Research)

• Diverticulosis and Diverticulitis

  (American College of Gastroenterology)

• Dietary Fiber: Essential for a Healthy Diet

  (Mayo Foundation for Medical Education and Research)

  Also in Spanish

• Diverticulitis Diet

  (Mayo Foundation for Medical Education and Research)

  Also in Spanish

• Diverticulitis: Can Certain Foods Trigger an Attack?

  (Mayo Foundation for Medical Education and Research)

  Also in Spanish

• Fiber: How to Increase the Amount in Your Diet

  (American Academy of Family Physicians)

  Also in Spanish

• Diverticula, Diverticulosis, Diverticulitis: What’s the Difference?

  (International Foundation for Gastrointestinal Disorders)

• ClinicalTrials. gov: Diverticular Diseases

  (National Institutes of Health)

• ClinicalTrials.gov: Diverticulitis

  (National Institutes of Health)

• Article: Effects of sarcopenia and myosteatosis are alleviated in reduced port surgery. ..

• Article: Incidence and risk factors of blowout within 90 days after a primary…

• Article: Novel method combining endoscopic band ligation and clipping for hemostasis of. ..

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• American Society of Colon and Rectal Surgeons

• Find a Gastroenterologist

  (American College of Gastroenterology)

• National Institute of Diabetes and Digestive and Kidney Diseases

Symptoms, Causes, Diagnosis, Treatment, Surgery

Written by WebMD Editorial Contributors

Medically Reviewed by Neha Pathak, MD on September 16, 2021

• What Is Diverticulitis?
• What Are the Symptoms of Diverticulitis?
• What Causes Diverticulitis?
• What Are the Complications of Diverticulitis?
• How Is Diverticulitis Diagnosed?
• How Is Diverticulitis Treated?
• More

Diverticulitis is the infection or inflammation of pouches that can form in your intestines. These pouches are called diverticula.

The pouches generally aren’t harmful. They can show up anywhere in your intestines. If you have them, it’s called diverticulosis. If they become infected or inflamed, you have diverticulitis.

Sometimes, diverticulitis is minor. But it can also be severe, with a massive infection or perforation (your doctor will call it a rupture) of the bowel.

You can have the pouches and not know it. The diverticula are usually painless and cause few symptoms, if any. But you might notice:

• Cramping on the left side of your abdomen that goes away after you pass gas or have a bowel movement
• Bright red blood in your poop

Diverticulitis symptoms are more noticeable and include severe abdominal pain and fever.

Diverticulitis can be acute or chronic. With the acute form, you may have one or more severe attacks of infection and inflammation. In chronic diverticulitis, inflammation and infection may go down but never clear up completely. Over time, the inflammation can lead to a bowel obstruction, which may cause constipation, thin stools, diarrhea, bloating, and belly pain. If the obstruction continues, abdominal pain and tenderness will increase, and you may feel sick to your stomach or throw up.

Doctors aren’t sure. Some studies suggest that your genes might play a role.

The pouches on your intestines get inflamed or infected when they tear or become blocked by feces.

If you have more bad germs than good ones in your gut, that might cause it, too.

Your chances of getting diverticulitis rise with age. It’s more common in people over 40. Other risk factors include:

• Being overweight
• Smoking cigarettes
• Not getting enough exercise
• Eating lots of fat and red meat but not much fiber
• Taking certain kinds of drugs, including steroids, opioids, and nonsteroidal anti-inflammatories like ibuprofen or naproxen
   

If you don’t treat it, diverticulitis can lead to serious complications that require surgery:

• Abscesses, collections of pus from the infection, may form around the infected diverticula. If these go through the intestinal wall, you could get peritonitis. This infection can be fatal. You’ll need treatment right away.
• Perforation or tearing in the intestinal wall can lead to abscesses and infection because of waste leaking into the abdominal cavity.
• Scarring can lead to a stricture or blockage of the intestine.
• Fistulas can develop if an infected diverticulum reaches a nearby organ and forms a connection. This most often happens between the large intestine and the bladder. It can lead to a kidney infection. Fistulas can also form between the large intestine and either the skin or the vagina.
• Stricture, which happens when the colon narrows in the affected area.

If you have severe bleeding, you may need a blood transfusion.

The symptoms of diverticulitis can also look like other problems. Your doctor will narrow things down by ruling out other issues. They’ll start with a physical exam. Women may get a pelvic exam, too. Your doctor may then order one or more tests, including:

• Blood, urine, and stool tests to look for infection
• CT scans to look for inflamed or infected diverticula
• A liver enzyme test to rule out liver problems

If your diverticulitis is mild, your doctor will suggest rest and a liquid diet while your intestines heal. They might also give you antibiotics to treat the infection.

Your doctor may also suggest that you take a mild pain reliever like acetaminophen.

You may go on a liquid or “diverticulitis diet.” You’ll start by drinking only clear liquids, such as water, broth, non-pulpy juices, ice pops, and plain tea or coffee. As you start to feel better, you can add low-fiber foods such as eggs, yogurt, and cheese, and white rice and pasta. These foods are gentle on your digestive system.

This treatment works well for most people who have clear-cut cases of diverticulitis.

In more severe cases, you might need to stay in the hospital and take antibiotics that are intravenous (injected into your veins). If you have an abdominal abscess, your doctor will drain it. If your intestine is ruptured or you have peritonitis, you’ll need surgery.

There are two main types:

• Primary bowel resection. In this procedure, your surgeon will remove diseased parts of the intestine and reconnect the healthy sections. You can have normal bowel movements afterward.
• Bowel resection with colostomy. This needs to be done if there’s so much swelling that the surgeon can’t reconnect your colon to your rectum right away. Your doctor will create an opening in your abdominal wall so waste can flow into a bag. Surgeons can often reconnect the bowel after the inflammation has passed.

The kind of operation you need depends on the type of complication you have and how serious it is.
When you’re healed, your doctor might give you a colonoscopy to rule out colon cancer.

You can prevent diverticulosis and diverticulitis and their complications by eating plenty of fiber, drinking lots of water, and exercising regularly.

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Diverticular disease (diverticulosis) of the colon

What is diverticular disease (diverticulosis) of the colon?

Diverticula (lat. diverticulum – literally “branch”, “road to the side”) are sac-like protrusions of all layers of the colon wall or only the mucous membrane and submucosal layer through a defect in the muscular layer.

Figure 1. Cross section of the colon. Diverticulum

Colon diverticulosis is a condition in which there is at least one diverticulum in the colon.

Figure 2. Diverticulosis of the left departments of the colon of

Diverticular disease – a disease characterized by clinical manifestations of the inflammatory process and its possible complications – abscesses, perforation of diverticulums, the formation of fistulas, peritonitis, as well as bleeding.

What is the anatomy of the large intestine?

To better understand the pathogenesis of diverticular disease, consider the anatomy of the colon. The large intestine is a hollow muscular organ – a “tube” located in the abdominal cavity in the shape of a “horseshoe”, and is the final section of the gastrointestinal tract, where the formation and evacuation of feces occurs. It consists of the following sections: appendix, cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum.

The wall of the large intestine consists of four layers: mucous, submucosal, muscular and serous.

Colon mucosa is its inner membrane facing the lumen. It is a thin layer of cells – a cylindrical epithelium. The mucous membrane lies on its own plate, consisting of loose fibrous connective tissue, in which the glands, blood and lymphatic vessels are located. In the deepest layer of the mucous membrane, on the border with the submucosa, there is a muscular plate of the mucous membrane. The epithelium of the mucous membrane performs an integumentary function, is a link between the wall of the large intestine and its lumen – it ensures the absorption of water, the synthesis of B and K vitamins by intestinal bacteria, the formation of fecal masses and their preparation for evacuation, releasing the required amount of mucus.

The submucosa is the layer of the colon wall following the muscularis mucosa. The submucosa contains blood vessels that feed the intestinal wall and nerve plexuses that coordinate its contractions. Due to the submucosa, the mucosa can shift in relation to the next layers of the colon wall and form folds.

Muscle fibers of the intestinal wall are arranged both circularly and longitudinally. This layer acts as a framework, and also ensures the promotion of fecal masses due to contractions.

Outside, the large intestine is covered with a thin “film” – a serous membrane.

For a better understanding of the mechanism of diverticulum formation, one should also pay attention to the peculiarities of the blood supply to the colon wall.

The colon is nourished from the system of superior and inferior mesenteric arteries, originating from the aorta, the main vessel of our body. Their branches form a single marginal vessel that accompanies the large intestine throughout its entire length. Feeding branches depart from the marginal vessel, passing through the muscle layer and branching in the submucosa. With an increase in pressure inside the intestine, sections of the muscular layer through which the feeding vessels pass can serve as a “gateway” for the formation of diverticula.

How does diverticular disease manifest itself?

Uncomplicated diverticulosis is usually asymptomatic – you may not even notice the disease. Diverticula may be an incidental finding during a routine examination. In this situation, no special treatment is required. Recommendations include regular medical supervision, a diet high in fiber and low in refined carbohydrates, and regular physical activity and weight control.

The difficulty of timely detection of diverticular disease lies in the absence of specific symptoms. The clinical picture is presented mainly by cramping pains mainly on the left lower abdomen, increased gas formation, unstable stools with a tendency to constipation or with alternating constipation and diarrhea. Such complaints are mainly associated with dysmotility of the colon.

When they see a doctor, such patients are usually diagnosed with irritable bowel syndrome or dolichosigma, the patient is reassured, an abdominal ultrasound is recommended, and after light therapy, they are sent “home”.

However, in the event of such complaints, a colonoscopy is mandatory! The above symptoms can be manifestations not only of diverticular disease, but also of many other diseases of the colon, the timely detection of which can significantly improve the results of treatment.

Figure 3. Colonoscopy. Orifices of diverticula are visible

The clinical picture of diverticulitis is significantly different. Severe abdominal pain, bloating, lack of stool, may be accompanied by fever, nausea, and vomiting. Such complaints require urgent hospitalization in the coloproctology department, where patients receive antibacterial, anti-inflammatory therapy, and if this treatment is not effective enough, surgical intervention may be necessary.

The main cause of inflammation of a diverticulum – diverticulitis – is the ingestion of dense fecal masses that are unable to come out. At this stage, inflammatory changes and the formation of an infiltrate (seal) of the surrounding tissues occur.

What causes diverticula?

Often at the doctor’s office, patients diagnosed with diverticular disease ask the question: “Why did this disease develop?” What are the causes of this disease? A large amount of information on the Internet does not always give a clear explanation. Let’s try to tell in more detail.

We believe that all the main causes of diverticular disease can be divided into two interrelated groups:

• Increased pressure in the intestinal lumen;
• Weakness of the intestinal wall.

Deficiency of vegetable fiber in the diet leads to a decrease in the volume and increase in the density of feces, which causes disturbances in the motor activity of the large intestine: even to a slight irritation, it reacts with chaotic contractions. Thus, short closed segments of the intestine appear with increased intraluminal pressure, which leads to bulging of the mucosa through the “weak” sections of the intestinal wall – the places where the blood vessels pass.

For a clear understanding of the formation of a diverticulum, we offer you an interesting comparison:

“The wall of the intestine is similar to the layered structure of a soccer ball – strong and hard skin on the outside, and a soft but elastic rubber chamber inside.

Now imagine that a hole, a hole, is formed in the outer hard shell of this ball. What will happen then? The high pressure inside the ball will push part of the soft and elastic inner rubber chamber outward: a pocket protruding outward is formed. This can be compared with a hernia on the abdomen – through a defect in the muscles, the contents “bulge out” outward.

Approximately the same thing happens with the large intestine in diverticulosis. If the pressure inside the intestinal lumen is large, and there are weak spots in the muscular layer, then the inner lining of the intestine tends outward through these holes, forming protrusions in the form of sacs. They are called diverticula.”

What tests should be performed if diverticular disease is suspected?

The first step in the diagnosis of diverticular disease without exacerbation is colonoscopy. With the help of a video camera inserted through the anus, more than a meter of the intestine is examined – the entire large intestine and the final section of the small intestine. Colonoscopy allows not only to see the presence of a diverticulum, but also to determine the size of its gate, the condition of the wall, and the exact localization. If other changes are found in the intestine, colonoscopy allows you to take a piece of tissue for examination – perform a biopsy with further histological examination in order to understand the microscopic structure of the changes. This study can be performed under light anesthesia, which allows you to completely save the patient from the discomfort associated with the procedure.

The “gold standard” for diagnosing diverticular disease is barium enema. This method allows you to determine the number of diverticula, their exact location, size and shape. The essence of the procedure is the introduction of a radiopaque preparation into the colon, after which a series of x-ray images are taken to assess the condition of the colon. In the presented photographs, the arrows indicate the orifices of the colonic diverticula. We marked with blue arrows multiple diverticula of the colon. This is what they look like on a CT scan.

Figure 4. Irrigoscopy. Diverticulosis of the colon

On x-ray images performed during irrigoscopy, multiple diverticula of the colon are clearly visible. They look like sacs filled with radiopaque.

Equally important methods are ultrasound diagnostics and computed tomography. Due to its minimally invasiveness, ease of implementation, ultrasound diagnostics is very relevant at the stage of the initial examination. It allows you to see the presence of diverticula, identify indirect signs of their inflammation, such as infiltration, abscess, or suggest a generalized form – peritonitis.

In order to clarify the data obtained during the ultrasound examination, in case of doubt and to clarify the diagnosis, a spiral computed tomography is performed. Virtual computed tomography allows you to recreate a three-dimensional image of the colon, including the affected areas. Using this technique, you can accurately determine the boundaries of the infiltrate or abscess, other organs involved in the inflammatory process.

Figure 5. Virtual colonoscopy. Orifice of diverticulum

How to treat diverticular disease, diverticulosis and diverticulitis?

Medical treatment

When treated promptly, diverticulitis responds very well to medical treatment. Inflammatory changes are completely cured with the help of antibacterial and anti-inflammatory therapy.

In case of complications of patients, the method of treatment should be selected the most minimally traumatic and minimally invasive. The infiltrate can be completely cured with medication. The abscess can be punctured under ultrasound or CT guidance.

Surgical treatment

In case of peritonitis and the need for surgery in the early stages of the disease, intervention can be performed laparoscopically – through small punctures. Unfortunately, the development of fecal peritonitis usually requires a laparotomy – a “large incision” for thorough washing and examination of the abdominal cavity.

Surgical treatment of diverticular disease outside periods of exacerbation is especially important for active travelers, as well as patients living far from district centers. If an exacerbation of the disease occurs away from centers where you can get quality medical care, the consequences can be the most unpleasant. If there are three or more attacks of diverticulitis per year, the patient should contact the coloproctology department to determine the optimal treatment tactics outside the exacerbation period. If surgical treatment is necessary, the operation of choice in this case is the laparoscopic removal of the affected area of ​​the colon and the rectosigmoid junction as one of the causes of increased pressure in the intestinal lumen. Removal of the stoma (even temporarily) in this case is not required.

When is emergency surgery necessary?

An urgent operation is necessary if purulent inflammation spreads to the peritoneum, i.e. peritonitis, which is a life-threatening complication.

Is the bowel always exposed to the anterior abdominal wall during an emergency operation?

This issue is decided individually for each patient. Of course, the formation of a stoma is not shown in 100% of cases.

Benefits of minimally invasive surgery for diverticulosis and diverticulitis

The main advantages of minimally invasive operations are a satisfactory cosmetic effect (no large scars remain on the anterior abdominal wall) and a faster patient recovery after surgery.

Will the intestine be exposed to the anterior abdominal wall (stoma formation) during a planned operation?

During planned surgical interventions for diverticulosis, the formation of an intestinal stoma is almost never required.

What happens after the operation?

You will be able to celebrate your recovery with your friends by strictly following your diet and doctor’s instructions.

Are there ways to prevent recurrence/recurrence of the disease?

First of all, avoid constipation and eating foods with small particles – nuts, seeds, fruits and vegetables with small stones.

How to choose a doctor and medical institution?

Choosing a clinic is a very important issue. Institutions with significant experience in the management of patients with diverticular disease should be selected. Our clinic employs specialists with extensive experience in performing minimally invasive operations.

Dear friends, if you or your loved ones have similar complaints or have already been diagnosed with diverticulosis, do not expect complications, you can always contact our clinic for advice, as well as modern treatment.

Diverticulitis

Diverticulitis

DIVERTICULOSIS, DIVERTICULAR DISEASE, DIVERTICULITIS

What is Diverticulitis?

Diverticulitis is an infection or inflammation of the saclike protrusions that can form in your intestines. These sacs are called diverticula.

Diverticula can appear anywhere in your intestines. If you have them, it’s called diverticulosis. If they become infected or inflamed, you have diverticulitis.

Sometimes diverticulitis is minor. But it can also be severe, with a massive infection or perforation (your doctor will call it a rupture) of the bowel.

Treatment of Diverticulitis

If your diverticulitis is mild, your doctor will suggest rest and a liquid diet until the inflammation in your gut subsides. They may also give you antibiotics to treat the infection.

In more severe cases, you may need to stay in the hospital and take intravenous antibiotics.

If an abscess develops, the surgeon will drain it.

The most common type of surgical intervention for all forms of diverticular disease is resection of the sigmoid colon (sigmoidectomy). The sigmoid colon is the section of the large intestine that runs just in front of the rectum, at the end of the intestine. This is the area where the strain of bowel movement exerts the greatest pressure on the intestinal wall, and therefore the greatest number of diverticula occur here. The operation involves removing the sigmoid colon as well as a small section of the rectum. Since diverticula can also occur in other parts of the intestine, it is usually not possible to remove them all. After the affected area of ​​the intestine is removed, the ends are sewn together again.

In most cases, this is a minimally invasive procedure that is performed by inserting instruments through small incisions in the abdominal wall (laparoscopy). But it can also be done by making a larger incision (open surgery). Our clinic has extensive experience in both open and laparoscopic interventions on the colon, but it should be noted that preference is given to minimally invasive technologies.

Complicated diverticulitis can lead to peritonitis (inflammation of the inner lining of the abdomen).

The pus can then spread into the abdomen and even cause blood poisoning. This is a medical emergency requiring urgent surgery. But this surgery usually doesn’t involve removing any sections of the bowel first. Instead, the abdomen is washed out and an artificial opening or an unnatural anus (colostomy) is formed. This is because the inflammation must completely disappear before the sigmoid colon is resected. A few months later, a resection of the sigmoid colon with closure of the colostomy can be performed.

If you have an intestinal rupture or peritonitis, you will need surgery. It is very important that during emergency operations, resection of the affected intestine may result in the removal of a colostomy – an unnatural anus on the anterior abdominal wall.

That is why your doctor can offer you a planned laparoscopic resection of the intestine, which will be completed without removing the unnatural anus.

Our clinic has extensive experience in laparoscopic colorectal interventions.

Decision-making

Until a few decades ago, people with diverticular disease were almost always advised to have surgery. Clinical guidelines currently urge physicians to do this only when absolutely necessary.