Diverticular disease and diverticulitis

Learn more about Diverticular disease and diverticulitis

Diverticular disease

Diverticular disease refers to small outpouchings of the wall of the colon. These pockets or ‘tics’, are very common, and can be considered a consequence of wear-and-tear in the bowel, akin to pot-holes in the road. 

In our Western population, diverticular disease is very common – almost like having wrinkles. It is present in 10% of those age 40 and increases to over 50% at age 60. It is believed that our modern diet has a chronic lack of fibre. This results in a less bulky stool, and the bowel then has to work harder and exert higher pressures to move the stool through the colon. Over time, these increased pressures result in the formation of a thick muscular bowel wall, and eventually diverticuli form at sites of weakness.

Diverticular disease and diverticulitis

Terminology related to Diverticular disease

Its confusing. The presence of pockets is called either: diverticular disease, diverticulosis, diverticulum or colloquially – ‘tics’. These all mean the same thing and in general, do not cause symptoms at this stage of the disease. Once formed, diverticuli do not disappear and most people suffer no ill-effects or symptoms. 

The usual recommendation for people with diverticular disease is to ensure adequate dietary fibre intake, and/or the use of a fibre supplement available from the pharmacist or supermarket (e.g. Metamucil, Benefibre, Nulax). The old advice to avoid grains, seeds or nuts have not been shown in large population studies to prevent complications, thus there is no good evidence that any particular foods should be avoided.

Diverticulitis is the most common complication of diverticular disease and occurs in approximately 15% of patients with diverticulosis. Diverticulitis refers to infection or inflammation associated with one or more of these pockets. This typically causes pain, most often in the left lower abdomen and the pain may be worse with movement. Severe cases are associated with more generalised and severe abdominal pain, fevers, loss of appetite and feeling unwell.

Complicated or uncomplicated diverticulitis

Uncomplicated diverticulitis may be managed in hospital or at home. New and convincing evidence suggests that straight-forward diverticulitis may not require antibiotics – but this is a change in long-standing tradition that is a little hard to shake! Many doctors still prescribe antibiotics for diverticulitis – it’s going to take time to get the message out. 

Antibiotics may still be used depending on the severity of the attack, findings on a CT scan, or if there are associated medical conditions.

Most diverticulitis will settle with time. It can come back though – the chance of a second attack of diverticulitis is about 30%.

Complicated diverticulitis refers to the formation of an abscess, leak or perforation of the bowel. This also results in pain and can have additional signs such as fevers, sweats and becoming more unwell. This may require antibiotics alone, drainage of any abscess, and sometimes emergency surgery. Complicated diverticulitis is normally managed in hospital. 

Surgery for diverticulitis

Surgery for diverticulitis is considered for each person differently. 

Surgery may be considered for repeat attacks, or for symptoms that persist after a first or subsequent attack. 

Surgery should be considered after a complicated diverticulitis – the chance of a further problem may be more likely. 

Ideally, surgery is done in an elective setting when the inflammation has settled, but is often required more urgently, and sometimes as an emergency.

Generally speaking, surgery aims to remove the worst of the diverticular disease and the affected segment or segments of colon. Surgery may require a washout and/or removal of the affected segment of the bowel. Surgery usually aims to join the bowel back together, but the individual details will be discussed with your colorectal surgeon.

As a follow-up for diverticulitis, particularly if you’ve never had one before, a colonoscopy is often performed. This is to confirm the presence of diverticular disease and often used as an opportunity to exclude the presence of bowel polyps and even bowel cancers. In uncomplicated diverticulitis, there seems to be no particular increased risk for bowel polyps or cancer.

Diverticular disease may also may also cause bleeding. This is usually dark-red/maroon and may be quite heavy, requiring hospital admission. Approximately 90% of the time, this bleeding will stop, but on occasion requires intervention. Any rectal bleeding warrants investigation by a colorectal surgeon.

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