Diverticular disease and diverticulitis: Overview – InformedHealth.org

Created: May 17, 2018; Next update: 2021.

Introduction

Diverticula are pouches in the lining of the intestine. They arise when the wall of the intestine bulges out through weak areas of intestinal muscle. The pouches are usually small and balloon-like, and the contents of the bowel (stool, or “poop”) might get into them. Although diverticula are often harmless, they may lead to bowel problems and cause pain. Simply put, there are three different conditions:

• Diverticulosis: The lining of the intestine bulges out in a number of places, but this doesn’t cause any symptoms or problems.

• Diverticular disease: The bulging pouches cause symptoms or lead to problems (complications).

• Diverticulitis: The pouches are inflamed or infected.

Diverticula can cause recurring or permanent symptoms. This is referred to as chronic diverticular disease. Diverticulitis can usually be treated effectively, but may have serious consequences if the inflammation spreads.

Diverticula and diverticulitis

Symptoms

Most diverticula don’t cause any symptoms. Diverticular disease is typically associated with pain in the lower left side of the abdomen (tummy) or – less commonly – the right side. It can also lead to bloating, constipation or diarrhea. The symptoms often go away for a while, but may be constant. They commonly get worse after meals, and then better again after going to the toilet and having a bowel movement. Sometimes diverticula lead to bleeding too.

If they become inflamed (diverticulitis), they cause sudden dull pain in the abdomen, accompanied by a mild fever. Other symptoms include constipation, diarrhea, bloating, nausea and sometimes cramping too. Diverticulitis rarely leads to vomiting. If a doctor applies pressure to the abdomen, the tummy muscles automatically tense up (a reflex known as muscular defense). If they suddenly let go, the pain gets worse.

Causes and risk factors

Diverticula form in weak areas of the intestinal muscles. They usually arise in the sigmoid colon. This s-shaped section of the large intestine is roughly 40 to 45 centimeter long and found just in front of the rectum. The contents of the intestine put the most pressure on the muscular wall here.

Some people are more likely to develop diverticula because of their genes. Further risk factors include weak connective tissue and problems with the wave-like movements of the intestinal wall. Older and very overweight people are at greater risk, too.

The influence of lifestyle factors hasn’t yet been properly determined. A diet that is low in fiber can lead to constipation and hard stools, so it seems logical that too little fiber should increase the risk of diverticular disease. Eating a lot of red meat, smoking and not getting enough movement are also believed to be risk factors.

It’s still not clear how diverticula become inflamed and what increases the risk of this happening. But inflammation is believed to be more likely in areas of reduced blood supply and if hard lumps of stool form in the diverticula.

Complications are more common in people who have a weakened immune system (for instance, after an organ transplant) or severe kidney disease. The long-term use of particular medications probably increases the risk of more serious complications. These medications include non-steroidal anti-inflammatory drugs (NSAIDs), steroids, acetylsalicylic acid (the drug in medicines like Aspirin) and opiates.

Prevalence

Many people have diverticula without knowing it. They are more common in older age: About 10% of people under the age of 50 have diverticula, and about 50% of people over the age of 70 have them. They are equally common in men and women.

About 1% of all people who have diverticula develop diverticulitis within ten years. This inflammation can occur at any age.

Effects

Diverticula often remain unnoticed if they don’t cause any symptoms. But they sometimes lead to chronic digestive problems and pain, or may even become inflamed or infected.

Diverticulitis can usually be treated effectively and then goes away after a few weeks. But about 20% of those affected get diverticulitis again within a few years.

Diverticulitis can lead to complications if the inflammation spreads to the wall of the intestine, surrounding tissue or nearby organs. Abscesses (collections of pus) or fistulas may develop. A fistula is an unnatural tunnel-like passageway between two organs, for instance between the intestine and the bladder.

One rare but serious complication may arise if the wall of the intestine tears (intestinal perforation). If the contents of the intestine then leak out into the abdominal cavity, the inner lining of the tummy (peritoneum) may become inflamed, leading to a life-threatening condition known as peritonitis. This typically causes severe tummy pain, a hard abdominal wall, fever, nausea, a rapid heartbeat and general weakness. It is important to recognize these peritonitis symptoms and quickly seek medical help.

In some people, diverticula keep becoming inflamed despite having been treated successfully in the past. This can lead to scarring that causes the intestine to become narrow (stenosis), making it difficult for stool to pass through it. In extreme cases, the intestine becomes blocked (ileus). Some people have constant diverticula symptoms although their intestine isn’t inflamed. The risk of complications is greatest when someone has diverticulitis for the first time. After that, recurring inflammations are a lot less likely to lead to complications. The main consequences of recurring diverticulitis are chronic symptoms such as irregular bowel movements, bloating and abdominal pain.

It’s good to know that diverticula do not develop into bowel cancer. This kind of cancer develops from polyps in the bowel.

Diagnosis

If you go to see a doctor about your symptoms, they will ask you about various things, such as your medical history and whether you are taking medication. This is followed by a physical examination where they listen to your tummy, and also feel your tummy and rectum. Depending on the symptoms, you may have blood and urine tests, and your temperature might be measured.  You will usually have an ultrasound scan as well. If there is still no clear diagnosis, you may need to have a CT (computed tomography) scan and perhaps a colonoscopy too (inspection of the inside of the intestine using a camera).

This can help to rule out other illnesses – the symptoms of diverticular disease are similar to the symptoms of conditions like appendicitis or irritable bowel syndrome (IBS).

Colonoscopies are too risky during acute diverticulitis. But people are often advised to have a colonoscopy about 4 to 6 weeks after the symptoms have cleared up. This is to make sure that they weren’t caused by polyps, bowel cancer or another illness.

Prevention

Eating enough fiber helps to make sure that your stool doesn’t get too hard. So it would seem logical that fiber should prevent pain and inflammation in people with diverticula. There’s a lot of fiber in whole-grain foods, vegetables, legumes (e. g. beans, lentils) and fruits. Physical exercise stimulates digestion too, but it isn’t clear whether it can prevent the symptoms.

Sometimes people are advised to avoid certain foods – particularly nuts, grains, sweetcorn and popcorn. For a long time it was thought that fragments of these foods could get stuck in the diverticula and cause diverticulitis. But studies have shown that not to be true. So you don’t have to avoid eating nuts, for example.

Treatment

Diverticula that don’t cause any symptoms don’t have to be treated. The treatment options for diverticulitis depend on how severe it is.

The aim of treatment is to

• avoid potential complications and relieve acute symptoms,

• prevent it from coming back, and

• relieve chronic symptoms.

Diverticulitis inflammations are caused by a bacterial infection, so they can be treated with antibiotics. But people usually only need to use antibiotics if complications arise or if there’s an increased risk of them arising. Complications may have to be treated in hospital.

If acute diverticulitis doesn’t improve or someone has constant symptoms, the affected part of the large intestine can be surgically removed. Because of the associated risks, it’s important to carefully consider the pros and cons of surgery first. Serious complications such as peritonitis require immediate surgery, though.

For people who have chronic symptoms, it might be worth trying to eat more fiber. There’s not yet enough good research to be able to say whether probiotic food products can help.

Nowadays there’s good reason to believe that antibiotics and surgery often aren’t as necessary as previously thought.

Sources

• Andeweg CS, Berg R, Staal JB, ten Broek RP, van Goor H. Patient-reported Outcomes After Conservative or Surgical Management of Recurrent and Chronic Complaints of Diverticulitis: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2016; 14(2): 183-190. [PubMed: 26305068]

• Carabotti M, Annibale B, Severi C, Lahner E. Role of Fiber in Symptomatic Uncomplicated Diverticular Disease: A Systematic Review. Nutrients 2017; 9(2): pii: E161. [PMC free article: PMC5331592] [PubMed: 28230737]

• Lahner E, Bellisario C, Hassan C, Zullo A, Esposito G, Annibale B. Probiotics in the Treatment of Diverticular Disease. A Systematic Review. J Gastrointestin Liver Dis 2016; 25(1): 79-86. [PubMed: 27014757]

• Leifeld L, Germer CT, Böhm S, Dumoulin FL, Häuser W, Kreis M et al. S2k-Leitlinie Divertikelkrankheit/Divertikulitis. Z Gastroenterol 2014; 52(7): 663-710. [PubMed: 25026009]

• Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid diverticulitis: a systematic review. JAMA 2014; 311(3): 287-297. [PubMed: 24430321]

• IQWiG health information is written with the aim of helping
  people understand the advantages and disadvantages of the main treatment options and health
  care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the
  German health care system. The suitability of any of the described options in an individual
  case can be determined by talking to a doctor. We do not offer individual consultations.

  Our information is based on the results of good-quality studies. It is written by a
  team of
  health care professionals, scientists and editors, and reviewed by external experts. You can
  find a detailed description of how our health information is produced and updated in
  our methods.

Diverticular disease and diverticulitis: Overview – InformedHealth.org

Created: May 17, 2018; Next update: 2021.

Introduction

Diverticula are pouches in the lining of the intestine. They arise when the wall of the intestine bulges out through weak areas of intestinal muscle. The pouches are usually small and balloon-like, and the contents of the bowel (stool, or “poop”) might get into them. Although diverticula are often harmless, they may lead to bowel problems and cause pain. Simply put, there are three different conditions:

• Diverticulosis: The lining of the intestine bulges out in a number of places, but this doesn’t cause any symptoms or problems.

• Diverticular disease: The bulging pouches cause symptoms or lead to problems (complications).

• Diverticulitis: The pouches are inflamed or infected.

Diverticula can cause recurring or permanent symptoms. This is referred to as chronic diverticular disease. Diverticulitis can usually be treated effectively, but may have serious consequences if the inflammation spreads.

Diverticula and diverticulitis

Symptoms

Most diverticula don’t cause any symptoms. Diverticular disease is typically associated with pain in the lower left side of the abdomen (tummy) or – less commonly – the right side. It can also lead to bloating, constipation or diarrhea. The symptoms often go away for a while, but may be constant. They commonly get worse after meals, and then better again after going to the toilet and having a bowel movement. Sometimes diverticula lead to bleeding too.

If they become inflamed (diverticulitis), they cause sudden dull pain in the abdomen, accompanied by a mild fever. Other symptoms include constipation, diarrhea, bloating, nausea and sometimes cramping too. Diverticulitis rarely leads to vomiting. If a doctor applies pressure to the abdomen, the tummy muscles automatically tense up (a reflex known as muscular defense). If they suddenly let go, the pain gets worse.

Causes and risk factors

Diverticula form in weak areas of the intestinal muscles. They usually arise in the sigmoid colon. This s-shaped section of the large intestine is roughly 40 to 45 centimeter long and found just in front of the rectum. The contents of the intestine put the most pressure on the muscular wall here.

Some people are more likely to develop diverticula because of their genes. Further risk factors include weak connective tissue and problems with the wave-like movements of the intestinal wall. Older and very overweight people are at greater risk, too.

The influence of lifestyle factors hasn’t yet been properly determined. A diet that is low in fiber can lead to constipation and hard stools, so it seems logical that too little fiber should increase the risk of diverticular disease. Eating a lot of red meat, smoking and not getting enough movement are also believed to be risk factors.

It’s still not clear how diverticula become inflamed and what increases the risk of this happening. But inflammation is believed to be more likely in areas of reduced blood supply and if hard lumps of stool form in the diverticula.

Complications are more common in people who have a weakened immune system (for instance, after an organ transplant) or severe kidney disease. The long-term use of particular medications probably increases the risk of more serious complications. These medications include non-steroidal anti-inflammatory drugs (NSAIDs), steroids, acetylsalicylic acid (the drug in medicines like Aspirin) and opiates.

Prevalence

Many people have diverticula without knowing it. They are more common in older age: About 10% of people under the age of 50 have diverticula, and about 50% of people over the age of 70 have them. They are equally common in men and women.

About 1% of all people who have diverticula develop diverticulitis within ten years. This inflammation can occur at any age.

Effects

Diverticula often remain unnoticed if they don’t cause any symptoms. But they sometimes lead to chronic digestive problems and pain, or may even become inflamed or infected.

Diverticulitis can usually be treated effectively and then goes away after a few weeks. But about 20% of those affected get diverticulitis again within a few years.

Diverticulitis can lead to complications if the inflammation spreads to the wall of the intestine, surrounding tissue or nearby organs. Abscesses (collections of pus) or fistulas may develop. A fistula is an unnatural tunnel-like passageway between two organs, for instance between the intestine and the bladder.

One rare but serious complication may arise if the wall of the intestine tears (intestinal perforation). If the contents of the intestine then leak out into the abdominal cavity, the inner lining of the tummy (peritoneum) may become inflamed, leading to a life-threatening condition known as peritonitis. This typically causes severe tummy pain, a hard abdominal wall, fever, nausea, a rapid heartbeat and general weakness. It is important to recognize these peritonitis symptoms and quickly seek medical help.

In some people, diverticula keep becoming inflamed despite having been treated successfully in the past. This can lead to scarring that causes the intestine to become narrow (stenosis), making it difficult for stool to pass through it. In extreme cases, the intestine becomes blocked (ileus). Some people have constant diverticula symptoms although their intestine isn’t inflamed. The risk of complications is greatest when someone has diverticulitis for the first time. After that, recurring inflammations are a lot less likely to lead to complications. The main consequences of recurring diverticulitis are chronic symptoms such as irregular bowel movements, bloating and abdominal pain.

It’s good to know that diverticula do not develop into bowel cancer. This kind of cancer develops from polyps in the bowel.

Diagnosis

If you go to see a doctor about your symptoms, they will ask you about various things, such as your medical history and whether you are taking medication. This is followed by a physical examination where they listen to your tummy, and also feel your tummy and rectum. Depending on the symptoms, you may have blood and urine tests, and your temperature might be measured.  You will usually have an ultrasound scan as well. If there is still no clear diagnosis, you may need to have a CT (computed tomography) scan and perhaps a colonoscopy too (inspection of the inside of the intestine using a camera).

This can help to rule out other illnesses – the symptoms of diverticular disease are similar to the symptoms of conditions like appendicitis or irritable bowel syndrome (IBS).

Colonoscopies are too risky during acute diverticulitis. But people are often advised to have a colonoscopy about 4 to 6 weeks after the symptoms have cleared up. This is to make sure that they weren’t caused by polyps, bowel cancer or another illness.

Prevention

Eating enough fiber helps to make sure that your stool doesn’t get too hard. So it would seem logical that fiber should prevent pain and inflammation in people with diverticula. There’s a lot of fiber in whole-grain foods, vegetables, legumes (e.g. beans, lentils) and fruits. Physical exercise stimulates digestion too, but it isn’t clear whether it can prevent the symptoms.

Sometimes people are advised to avoid certain foods – particularly nuts, grains, sweetcorn and popcorn. For a long time it was thought that fragments of these foods could get stuck in the diverticula and cause diverticulitis. But studies have shown that not to be true. So you don’t have to avoid eating nuts, for example.

Treatment

Diverticula that don’t cause any symptoms don’t have to be treated. The treatment options for diverticulitis depend on how severe it is.

The aim of treatment is to

• avoid potential complications and relieve acute symptoms,

• prevent it from coming back, and

• relieve chronic symptoms.

Diverticulitis inflammations are caused by a bacterial infection, so they can be treated with antibiotics. But people usually only need to use antibiotics if complications arise or if there’s an increased risk of them arising. Complications may have to be treated in hospital.

If acute diverticulitis doesn’t improve or someone has constant symptoms, the affected part of the large intestine can be surgically removed. Because of the associated risks, it’s important to carefully consider the pros and cons of surgery first. Serious complications such as peritonitis require immediate surgery, though.

For people who have chronic symptoms, it might be worth trying to eat more fiber. There’s not yet enough good research to be able to say whether probiotic food products can help.

Nowadays there’s good reason to believe that antibiotics and surgery often aren’t as necessary as previously thought.

Sources

• Andeweg CS, Berg R, Staal JB, ten Broek RP, van Goor H. Patient-reported Outcomes After Conservative or Surgical Management of Recurrent and Chronic Complaints of Diverticulitis: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2016; 14(2): 183-190. [PubMed: 26305068]

• Carabotti M, Annibale B, Severi C, Lahner E. Role of Fiber in Symptomatic Uncomplicated Diverticular Disease: A Systematic Review. Nutrients 2017; 9(2): pii: E161. [PMC free article: PMC5331592] [PubMed: 28230737]

• Lahner E, Bellisario C, Hassan C, Zullo A, Esposito G, Annibale B. Probiotics in the Treatment of Diverticular Disease. A Systematic Review. J Gastrointestin Liver Dis 2016; 25(1): 79-86. [PubMed: 27014757]

• Leifeld L, Germer CT, Böhm S, Dumoulin FL, Häuser W, Kreis M et al. S2k-Leitlinie Divertikelkrankheit/Divertikulitis. Z Gastroenterol 2014; 52(7): 663-710. [PubMed: 25026009]

• Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid diverticulitis: a systematic review. JAMA 2014; 311(3): 287-297. [PubMed: 24430321]

• IQWiG health information is written with the aim of helping
  people understand the advantages and disadvantages of the main treatment options and health
  care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the
  German health care system. The suitability of any of the described options in an individual
  case can be determined by talking to a doctor. We do not offer individual consultations.

  Our information is based on the results of good-quality studies. It is written by a
  team of
  health care professionals, scientists and editors, and reviewed by external experts. You can
  find a detailed description of how our health information is produced and updated in
  our methods.

Not everything that hurts in the stomach is diverticulitis

Almost all people develop diverticula sooner or later in the colon. Someone at 40 years old, at 80 years old – the majority. Diverticula are protrusions-vesicles, most often found closer to the exit, in the sigmoid colon. It’s on the bottom left.

Usually they do not ask for food and do not interfere with life. But they can flare up. It turns out such a saccular protrusion with an accumulation of pus. More often this trouble is preceded by constipation or diarrhea.

At the reception, a person who has pain on the left side of the bottom for 5 years almost every day and for many hours. Colonoscopy revealed large diverticula. He is treated with antibiotics and mesalazine, but there is no improvement. And diverticulitis is not present and was not. Long-term monotonous pain is always a functional disorder, treated with drugs such as duloxetine and pregabalin.

How do we know that diverticulitis has appeared? By complaints. More often the patient says that there was constipation (rarely diarrhea), then cramping or constant pain appeared, usually on the left lower abdomen. Pain “reacts” to going to the toilet. Sometimes shaking of the body while walking. Often the temperature rises, the person experiences a general malaise.

Next we touch the stomach, usually we find local pain in the sigmoid colon. There may be “peritoneal” symptoms. Remember, the doctor, when palpating the abdomen, presses locally on the abdomen, and then abruptly removes his hand? If at the time of removal of the hand the pain increased sharply, the inflammation probably went beyond the intestine and affected the peritoneum. At this point, it is good to do a clinical blood test and see the C-reactive protein. In some clinics, such analyzes are available in real time.

The doctor receives signs of inflammation from tests. In principle, this is sufficient for the diagnosis of diverticulitis. We will prescribe treatment and everything will be fine soon. But one of my patients in this situation was scheduled for a colonoscopy, “to be sure.” First, preparation with a washing preparation, then the colonoscopy itself with bowel inflation. They saw an inflamed diverticulum, although they might not have seen it. The manipulations led to a perforation (hole) in the diverticulum and an emergency operation, in which the patient’s sigmoid colon was removed. It’s a shame that colonoscopy – a very useful method in many cases – for suspected diverticulitis was unnecessary and harmful.

If the clinical and laboratory picture is not enough for us, we prescribe computed tomography, sometimes ultrasound. Why? These methods “see” the inflammation (fluid or infiltrate) that has already gone beyond the intestine to the peritoneum. And perforation will also be shown – free air outside the intestines, which should not be. The methods themselves do not increase the risk of complications.

What to do next? Uncomplicated diverticulitis does not require hospitalization. But it is often offered, common sense is against it, the interests of the patient are against it, but the fear of the investigator is a strong argument for it. Fear is a bad adviser to a bad doctor.

If inflammation does not come out of the diverticulum, it can be treated with intestinal septic – an antibiotic that is not absorbed, today it is rifaximin.

If it went to the peritoneum, they used to try to operate. This is an extreme measure. A systemic antibiotic is almost always sufficient. Diverticulitis usually resolves in 1 to 3 weeks.

What’s next? It all depends on how often the diverticulitis comes back. It is important to prevent constipation by using vegetable fiber, fiber from preparations such as psyllium, synthetic fiber analogues such as macrogol.

Remember when I wrote that my patient was prescribed mesalazine? Some hopes were pinned on it at one time, but it turned out to be good in ulcerative colitis, its effect is hardly noticeable or absent in the prevention of diverticulitis.

Various regimens of rifaximin are given prophylactically. It is important that diverticulitis is initially suspected to see a doctor immediately and receive a timely prescription of an antibiotic – this, previously considered a “surgical” disease, will almost always reverse.

Why do I tell patients this? Because you don’t have to be a doctor to understand this, it’s enough to have common sense. Our patients have it.

What is diverticulosis and should it be treated

In half of the elderly, doctors detect diverticulosis – multiple protrusions of the intestinal walls. What kind of disease it is, why it is dangerous and whether it can be prevented, Gazeta.Ru sorted it out.

Diverticulosis is a multiple formation of diverticula, sac-like protrusions of the wall of a hollow or internal organ. Most often, diverticula form in the digestive tract. The disease can be either congenital or acquired. In the first case, the diverticulum consists of all the membranes of the organ – serous, muscular, mucosal and submucosal. These include, in particular, Meckel’s diverticulum – a protrusion of the wall of the ileum caused by incomplete fusion of the vitelline duct, which is involved in the nutrition of the embryo in the womb.

It occurs in 2% of the population and is the most common congenital pathology of the gastrointestinal tract.

Acquired diverticula are protrusions of the submucosa and mucosa between individual bundles of the muscularis.

The most common site for diverticula formation is the intestines.

Colon diverticula are found in only 5% of patients under 50 years of age, 30% of patients over 50 years of age, and 50% of patients over 70 years of age.

In 70% of cases of intestinal diverticulosis, diverticula are located in the sigmoid colon. This is due to its anatomical and functional features: a smaller diameter, a large number of bends, and a denser consistency of the content. In addition, it has a reservoir function, which increases the pressure on its walls.

More rarely, diverticula of the small intestine develop. The most common place of their appearance is the duodenum.

Doctors find it difficult to identify specific causes of diverticula formation. The most common is the hernial theory, according to which diverticula occur due to the weakness of the connective tissue framework of the intestinal wall. And the violation of intestinal motility, characteristic of an aging organism, leads to an increase in intra-intestinal pressure, which causes protrusions of the mucosa in places of least resistance. The most common risk factor is older age.

In addition, recent studies show that the development of diverticulosis may be associated with vitamin D deficiency. So, when studying the lifestyle of 539 patients with diverticulosis and a control group of 1659 healthy subjects, researchers did not reveal links between a lack of fiber and the appearance of diverticula.

In 70% of cases, diverticulosis is asymptomatic.

However, diverticula can cause abdominal pain, diarrhoea, constipation, flatulence. To establish a diagnosis and exclude other causes of complaints, colonoscopy (endoscopic examination of the intestine) or irrigoscopy (X-ray examination of the intestine with the introduction of a radiopaque preparation into it) is performed, as well as computed tomography.

Some patients with diverticulosis experience diverticulitis, an inflammation of the diverticula. Previously, the number of such cases was estimated at 25% of the total number of patients. However, according to study 2013, the risk of developing diverticulitis with diverticulosis may be much lower. A 15-year follow-up of 2222 patients showed that only 1% of patients develop diverticulitis within seven years of diverticulosis. It occurs more often in patients who were diagnosed with diverticulosis at an earlier age.

“These bulges can often be found during colonoscopy, and patients wonder how dangerous they are and what to do about them,” the researchers explain.

In short, diverticulosis is not a cause for concern. The chances of complications are low.”

The characteristic symptoms of diverticulitis are pain and tension in the muscles of the anterior abdominal wall on the lower left, fever, chills, nausea and vomiting, constipation or diarrhea.

When a diverticulum is perforated into the abdominal cavity, a clinical picture of diffuse peritonitis develops. With perforation into the retroperitoneal tissue or between the sheets of the mesentery, abscesses and infiltrates occur.