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What is Diverticular Disease?
Diverticular (pronounced: die-ver-TIK-yoo-ler) disease is a common condition characterized by small sac-like out-pouchings of the inner bowel lining, which push through the outer wall of the large intestine or colon. These out-pouchings, called diverticula, occur most frequently in the lower part of the colon known as the sigmoid colon, which is located on the left side of the abdomen. Other parts of the colon may also be involved.
Diverticula can vary in number from a single finding to hundreds. In size, they are typically 5-10 mm in diameter but can exceed 2 cm. Extreme cases of diverticula have been described, with sizes up to 25 cm, but these are rare. Over time, diverticula usually increase in number and in size. Occasionally, the diverticula become inflamed, and this condition is known as diverticulitis.
What are the symptoms of Diverticular Disease?
The terms diverticular disease and diverticulosis include the presence of diverticula and all signs and symptoms that may result including pain, fever, abdominal cramping, bleeding, and bloating.
Diverticulosis is often present without symptoms but when symptoms do exist, they are usually similar to those of irritable bowel syndrome (IBS). There may be altered bowel function in the form of either constipation or diarrhea, or alternations between these. Crampy abdominal pain may occur, often associated with bowel activity. However, unlike IBS, there may be occasional bleeding into the bowel and this can show up in the stool. When diverticulitis arises, the bowel may be even more irritable, with increased diarrhea and cramps. There is often pain and tenderness in the left lower part of the abdomen, sometimes accompanied by fever.
Occasionally, a diverticulum may perforate causing a local abscess with a marked increase in pain and fever. Rarely, the perforation may be into the whole abdomen causing an acute condition requiring surgery.
How do these conditions occur?
Although the exact cause of diverticulosis is unknown, it becomes more prevalent with age and there appears to be a familial incidence. One theory is that diverticula occur when pressure, such as that caused by constipation, builds up inside the colon and makes the intestinal wall balloon out in spots where the wall is weak.
The bowel tends to become irritable and spastic when there is inadequate bulk passing through. With segmental areas of spasms, the pressure in the intervening areas can be very high, pushing out small pouches of the bowel at the weakest spots. These weak spots are the sites between the muscle bundles that run longitudinally up and down the colon.
The presence of irritating particles and bacteria within the diverticula may produce inflammation in and around the site, causing the condition mentioned above as diverticulitis.
The wide geographic variability of diverticular disease and its striking correlation with an urban diet has long suggested a dietary factor as its cause. History shows an increased diverticular disease incidence in Britain in the decades following the introduction of steel rolling mills in 1880, which greatly reduce the fibre content of milled grains. Around the same time, refined sugar was introduced, with a lesser use of crude grains. Additional support for the link between diet and diverticular disease stems from the observation that clinical diverticular disease began to emerge in the decades following these dietary modifications.
Although quite common in developed countries, with the highest incidences seen in the United States, Europe, and Australia, studies show that diverticular disease is rare in rural Africa and Asia. However, data in these studies arose during a period when lifespan in Africa was significantly less than that in Western populations, potentially affecting data results for this disease, which increases with age.
Who is most likely to develop Diverticular Disease?
Diverticular disease most frequently shows up in the older population and incidence does not seem to differ significantly by gender. Estimates for the prevalence of diverticular disease in Western populations are less than 5% in those under forty years of age, to 30% over 40, and 60% over 85 years of age. However, some newer evidence indicates diverticular disease may be more common than this in populations below the age of 50.
When looking at the gender differences among younger diverticular disease patients, there is a notable male predominance. The disease seems to be more virulent in these younger patients, with 25-80% reporting urgent surgery during their initial attack.
The precise prevalence of diverticular disease is difficult to measure, as many people have diverticula yet remain symptom free. Only about 10-25% of those with diverticula will develop diverticulitis, with its potential but rare complications of abscesses, fistulae, obstruction, and lower intestinal hemorrhage. After an initial episode, about 30-40% of these patients will have a repeat attack. Why diverticulitis develops in some patients with diverticular disease and not in others is unknown.
How is diverticulosis diagnosed?
The precise prevalence of colonic diverticulosis is difficult to measure accurately because, as mentioned, most patients are asymptomatic and the non-specific symptoms of diverticulosis overlap considerably with those of IBS.
The patient's history can reveal important clues to the physician, as does a careful physical examination. When diverticulitis is present, there is usually more tenderness over the abdomen and the patient typically exhibits more severe symptoms and usually has a fever.
Blood tests may reveal the degree of inflammation present.
Diverticular disease can be confirmed in a number of ways. The oldest testing method is by visualization of the bowel with a barium X-ray, involving a contrast medium inserted as an enema followed by an X-ray of the area. During a colonoscopy, a doctor views the intestinal tract with an instrument, called a scope, which enters the body via the anus. The scope is made of a hollow, flexible tube with a tiny light and video camera. These procedures require some advance bowel preparation and may require sedation. However, since most diverticula form in the lower (sigmoid) colon, sometimes doctors recommend a less invasive procedure, called a flexible sigmoidoscopy to view this portion of the bowel only. This usually does not require sedation. During periods of flare-up, the bowel may be too tender to perform these investigations and a CT (computer tomography) scan is recommended, as this procedure is even less invasive.
The physician also considers other conditions that could be causing the patient's symptoms, and will eliminate these as possibilities before confirming a diagnosis.
How Diverticular Disease treated?
In dietary management of diverticular disease, recommendations include consuming well-balanced meals with a high fibre content and adequate fluid intake.
It is important to note, however, that existing diverticula do not get smaller or go away with a high fibre diet, but there are overall health benefits and a diminished likelihood of new pouches forming.
There is no evidence that excluding whole pieces of fibre, such as nuts, corn, and seeds, will benefit the disease course. Sometimes antispasmodic medication may provide relief, but it could be that this is treating a co-existing irritable bowel rather that the diverticular disease itself. When diverticulitis is present, the patient should switch from a high-fibre diet and allow the bowel to rest. This means a restricted-fibre diet or a fluid diet along with physical rest. Antibiotics are usually required and antispasmodics and analgesics (pain medication) may be of value. In severe cases, the doctor may admit the patient to hospital for intravenous feeding so that the bowel may rest for a few days.
Dietary Changes
Patients with diverticular disease should discuss the gradual addition of fibre into their diet with a physician or dietitian.
Dietary fibre is a group of plant substances (lignin, cellulose, hemicellulose, pectin, and gums) that human intestinal enzymes cannot break down. When considering fibre, it is important to look at both the content and the type of fibre in selected foods. There are two types of fibre: water-insoluble and water-soluble.
Water-insoluble fibres absorb and retain water, accelerate the transit time of gastrointestinal contents and thus help to prevent constipation. Water-insoluble fibres include lignin (found in vegetables), cellulose (found in wheat), and hemicellulose (found in cereals and vegetables). Cellulose and hemicellulose increase stool bulk, which helps with muscle tone in the colon and makes it less susceptible to the bulging, out-pouches seen in diverticular disease. Wheat bran, whole grain breads and cereals, and brown rice are all good sources of insoluble fibre.
Water-soluble fibres include pectin from citrus and other fruits, and gums from certain vegetables, oats, barley, and legumes. Pectins and gums work by forming a gel with water, making the contents firmer so that food progresses through the digestive tract more slowly. The following (partial) list of foods contain soluble fibre: fruits such as apples, bananas, grapefruit, oranges, strawberries; vegetables such as cabbage, cauliflower, peas, potatoes; grains such as oatmeal, oat bran, barley; and legumes such as lentils, dried peas, and beans.
When consuming higher fibre foods, it is essential to drink at least six to eight glasses of fluid per day. Occasionally, one of the many commercially prepared fibre compounds on the market such as Metamucil®, Benefibre®, FibreSure™ or Prodiem® may be indicated. Cooking does not generally alter the fibre content of food.
Can diverticulosis be prevented?
The best preventative would seem to be a well-balanced high-fibre diet beginning as early on in life as possible. Gradual introduction of fibre into the diet is essential and, while increasing fibre, symptoms may become worse for a period before they improve. The primary way that increased fibre helps is by reducing incidents of constipation. Although there have been multiple uncontrolled studies demonstrating the beneficial effect of fibre supplements in patients with non-specific symptoms and diverticulosis, lack of a placebo group in these studies make any such data suspect.
Although randomizing human children to a lifelong high- or low-fibre diet is impractical, the theory that diverticulosis is preventable is supported by analysis of the Health Professionals Follow-up Study, which followed 51,529 US male health professionals. During a 6-year period, there were 385 new cases of symptomatic diverticular disease. The study found a significant inverse association between insoluble dietary fibre intake and the risk of subsequently developing symptomatic diverticular disease.
Studies show that fruits and vegetables seem to offer more protection than cereal fibres. There also seems to be a similar protective component from physical activity. However, a high intake of total fat and red meat may increase the risk of the disease.
Is surgery necessary?
With diverticular disease, surgery is generally not required as diet modification and medications are usually enough to control symptoms.
Attacks of diverticulitis may respond to medical management but if they become frequent, surgical resection of the affected segment of bowel may be necessary. This occurs in only about 1% of diverticular patients and may be in the form of either emergency or elective surgery. In many cases, the surgeon will be able to remove the damaged portion of the bowel and connect the remaining ends together. If this is not safe or possible, the surgeon may perform a procedure called colostomy, in which an opening is created in the abdomen and the colon connected to this hole. A bag, called an appliance, is then fitted around the hole to collect the body’s waste material.
A colostomy may be either temporary or permanent, depending upon the particular situation. If perforation of a diverticulum with abscess formation occurs, it may be necessary to have a temporary colostomy until the infection has cleared. The bowel may be re-joined once the area has healed.
Quick Review of Diverticular Disease
diverticula (plural of diverticulum) – small sac-like out-pouchings protruding through the outer layers of the colon
diverticulitis – the inflammation of diverticula and its accompanying symptoms
diverticulosis/diverticular disease – the presence of one or more diverticula and all signs and symptoms that may result
For most people the disease remains asymptomatic; however, for some, these diverticula become inflamed leading to symptoms of abdominal pain, diarrhea, constipation, and bloating (diverticulitis)
For most patients, diverticulosis can be managed by consuming a high-fibre diet, and switching to a low-fibre diet during bouts of diverticulitis
High-fibre foods include insoluble fibre from cereals, and soluble fibre from fruits and vegetables
Complications from diverticular disease are rare, and very occasionally surgical treatment is necessary
Always tell your doctor if you experience new or different symptoms, or if there is rectal bleeding, weight loss, fever, or chronic pain
Are you taking prescription medication for any of the following stomach problems/symptoms:
Stomach pain or discomfort
Heartburn
Sour taste in mouth/acid regurgitation
Excessive burping/belching
Increased abdominal bloating
Nausea
Early satiety
If you answer yes to any one of the symptoms listed above then take this test to see if your current medication is adequately controlling your stomach symptoms.
The PASS Test
PPI* Acid Symptom Suppression Test
*PPI is short for proton pump inhibitor, a class of medication used to suppress the acid in your stomach. These include Losec®, Nexium®, Pantoloc®, Pariet™, and Prevacid®.
