Diverticular disease refers to the presence of diverticuli in the colon. A diverticulum is simply a pocket, or an out-pouching that occurs at a site of relative weakness. These can be considered a consequence of wear-and-tear in the bowel, akin to pot-holes the road.
In a 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.
TERMINOLIGY RELATED TO DIVERTICULAR DESEASE
There is much confusion about the terminology related to diverticular disease. 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. 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 even 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 people with diverticular disease. 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
Complicated diverticulitis refers to the additional presence of an abscess, or an unconfined perforation in the bowel (which the body has been unable to seal). This will also result in pain, but also the additional signs fevers, sweats, a loss of appetite. In a free perforation, the pain will involve a larger region of the abdomen. This constitutes a more urgent situation that may require drainage of an abscess and/or an operation.
Uncomplicated diverticulitis is managed either at home or in hospital depending on the severity of symptoms. Uncomplicated diverticulitis is often treated with antibiotics, however current evidence suggests that antibiotics make no difference in recovering from the acute condition. There is certainly a role for antibiotics in the treatment of complicated diverticulitis. The chance of a second attack of diverticulitis is about 30%.
SURGERY FOR DIVERTICULITIS
Surgery for diverticulitis is considered when medical management fails, or may be necessary upfront in an emergency. This is uncommon. Surgery may require removal of the affected segment of the bowel, and sometimes the formation of a stoma (or a bag) which delivers waste onto the abdominal wall. In modern times, we are increasingly able to avoid the formation of a stoma and join the bowel ends together. The decision to do this depends on many factors.
Elective surgery for diverticulitis depends on individual patient circumstances and needs to be discussed.
As follow-up for diverticulitis, 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 account for rectal 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.
OTHER CONDITIONS WE TREAT
An anal fistula is an abnormal connection from just inside the anal canal usually extending to the skin overlying the buttock
Haemorrhoids are the the enlargement of a small network of blood vessels just beneath the lining of the anal canal.