Diverticular Disease

A diverticulum is an outpouching of the bowel wall that is composed of mucosa. The are most commonly found in the sigmoid colon yet can be present throughout the large bowel and (less commonly) small bowel.

There are three different manifestations of diverticiulum:

  • Diverticulosis – the presence of diverticulum
  • Diverticular disease – symptomatic diverticulum
  • Diverticulitis – inflammation of the diverticulum

Diverticulosis is present in around 50% of >50yrs and 70% of >80yrs, yet only 25% of these cases become symptomatic. The disease affects more men than women (1.6:1) and is most prevalent in developed countries.

Pathophysiology

In an aging bowel that has naturally become weakened in certain areas over time, the movement of stool will cause an increase in luminal pressure. This results in a protrusion or outpouching of the mucosa through the weaker areas of the bowel wall, creating pockets in which bowel contents, including bacteria, can accumulate. The diverticulum, when inflamed, can perforate and result in peritonitis.

Fig. 1 - Laparoscopic view of diverticula in the sigmoid colon

Fig. 1 – Laparoscopic view of diverticula in the sigmoid colon


Risk Factors

The risk factors for the formation of diverticulum include low dietary fibre intake, obesity (in younger patients), smoking, family history, and NSAID use.


Clinical Features

A large proportion of individuals with diverticula remain asymptomatic, and are only found incidentally, such as during routine colonoscopy or CT imaging.

A patient with simple diverticular disease may present with left lower abdominal pain (typically a colicky pain, relieved by defecation), altered bowel habit, nausea, or flatulence.

Diverticulitis can present with a wide spectrum of clinical features, dependent on the specific complication of the diverticulum, including:

  • Abdominal pain and localised tenderness – classically in the left iliac fossa (a perforated diverticulum can present with signs of localised peritonism or generalised peritonitis)
    • If a patient is taking corticosteroids or immunosuppressants, this can mask the symptoms of diverticulitis, even if it has perforated
  • PR bleeding – usually sudden and sometimes painless
    • Large amount of blood and blood clots may be passed, even with minimal pain
  • Anorexia, nausea, or vomiting

A PR examination is most commonly unremarkable, yet in severe cases of the disease can reveal a mass present (secondary to abscess formation).

In severe or chronic cases, fistulae can form (most commonly colovesical or colovaginal). Colovesical fistula can present with pneumoturia, faecaluria, or recurrent UTIs, whilst colovaginal fistulas can present with copious vaginal discharge or recurrent vaginal infections.

Complications of Diverticular Disease

Younger patients with diverticular disease have been shown to have more active disease with higher re-occurrence and complication rates. Recurrent or chronic diverticular disease can result in the development of:

  • Bowel obstruction, secondary to stricture formation and can be managed either via stenting or bowel resection
  • Pericolic abscesses, which can be treated initially with antibiotics and bowel rest, before CT guided drainage or a laparoscopic washout are trialled as further management options
  • Fistula formation, often requiring surgical resection and repair

Differential Diagnosis

The important differential diagnoses for diverticular disease include inflammatory bowel disease or bowel cancer. It is therefore important to investigate any patient with suspected diverticular disease with an appropriate imaging study, such as flexible sigmoidoscopy.

Other causes of abdominal pain should be sought including appendicitis, mesenteric ischaemia, gynaecological causes, or renal stones.

 


Investigations

Laboratory Tests

Any patient with suspected diverticular disease should have initial routine blood tests performed, including FBC, U&Es, clotting, LFTs, and a Group & Save (or Crossmatch, pending degree of blood loss)

In severe cases or in suspected diverticulitis, a blood gas (either ABG or VBG) will be useful to assess the lactate level, assessing for any sepsis or bowel ischaemia.

A urine dipstick may prove helpful to exclude any urological causes (e.g. left renal colic or pyelonephritis).

Imaging

In a patient with suspected diverticular disease, a flexible sigmoidoscopy is a good initial approach as this will identify any obvious rectosigmoidal lesion. A sigmoidoscopy or colonoscopy should never be performed in any presenting cases of suspected diverticulitis, due to the increased risk of perforation.

Dependent on clinical findings, an abdominal X-ray (AXR) may be required to exclude obstruction and an erect chest X-ray (eCXR) should also be requested if a perforation is suspected.

CT abdo-pelvis scan can provide high level of accuracy in diagnosing symptomatic diverticular disease but is better utilised in patients where perforation or an alternative diagnosis is suspected. Contrast studies can be used to investigate any fistula that have developed.

Fig. 3 - CT scan for varying degrees of diverticular disease (1) diverticulum in the sigmoid colon (2) degree of diverticulitis present (3) abscess formation, secondary to ongoing diverticulitis

Fig. 3 – CT scan for varying degrees of diverticular disease (1) diverticulum in the sigmoid colon (2) degree of diverticulitis present (3) abscess formation, secondary to ongoing diverticulitis


Management

Patients with mild uncomplicated diverticulitis can often be managed at home with antibiotics, analgesia, and encouraging intake of clear fluids. Paracetamol is recommended as first line analgesia, as opioid-based analgesia may cause constipation and worsen the clinical course of the diverticular disease.

Hospital guidance varies regarding admitting patients with diverticular disease. However, the following features should be sought:

  • Pain is not controlled with simple analgesia or concerns of dehydration
  • The patient has significant co-morbidities or is immunocompromised
  • Significant PR bleeding
  • Suspicion of peritonitis, warranting imaging and active observation
  • Symptoms persisting for longer than 48 hours at home with conservative management

Conservative Management

Conservative management for a patient with suspected or confirmed diverticulitis is with broad-spectrum IV antibiotics, IV fluids, bowel rest (only clear fluids orally), and analgesia. Investigations should be ordered concurrently to confirm the suspected diverticulitis and assess severity. 

Any significant PR haemorrhage will need resuscitation with IV fluids and blood products. A diverticular bleed in most patients will be self-limiting* however options such as embolization, intra-arterial vasopressin, or surgical resection may be needed if cases do not settle with conservative approaches

*If a second bleeding episode occurs there is a significant chance of further episodes (up to 50%), hence it can be best to discuss early with interventional radiologists for planning further management options

Surgical Management

Surgery is eventually required in 15-30% of patients admitted. Indications for emergency surgery include:

  • Perforation with faecal peritonitis (mortality rate up to 50%)
  • Sepsis, not responding to antibiotic therapy
  • Failure to improve with conservative management

Emergency intervention will be either bowel resection (either with primary anastomosis or as a Hartmann’s procedure) or laparoscopic peritoneal lavage* (washout of an abscess).

recent meta-analysis showed no difference between resection vs. lavage for acute perforated diverticulitis in mortality, 30-day reoperations and unplanned readmissions, however lavage was associated with higher rates of intraabdominal abscesses, peritonitis, and increased long-term emergency reoperations.

*Lavage is often done in younger patients, those with higher BMIs, or low ASA grades, however no definitive guidelines exist for preferred surgical intervention

Elective surgical intervention may be indicated in patients with chronic symptoms, significant co-morbidities, immunosuppression, or recurrent disease. It may also be used in cases where a complicated diverticulitis was initially treated by percutaneous drainage.

Hartmann’s Procedure

A Hartmann’s procedure is an emergency surgical procedure whereby the affected area of colon (sigmoid colon) is resected, with the formation of an end colostomy and the closure of the rectal stump. An anastomosis with reversal of colostomy may be possible at a later date.

The before and after of the bowel following a Hartmann's Procedure

Fig. 4 – The before and after of the bowel following a Hartmann’s Procedure

 

Key Points

  • The three different manifestations of diverticiulae are diverticulosis, diverticular disease, and diverticulitis
  • Diverticulae formation is most commonly associated with a low-fibre diet
  • Diverticulitis can present with abdominal pain (commonly LLQ), evidence of systemic infection, or PR bleeding (often painless)
  • Most cases of diverticulitis can be treated conservatively, however surgical intervention is warranted in those with evidence of perforation, sepsis not responding to antibiotic therapy, or failure to improve despite conservative management

Quiz

Question 1 / 4
All of the following are risk factors for diverticulosis except?

Quiz

Question 2 / 4
A patient known to have diverticulosis and recurrent bouts of diverticulitis presents to the emergency room with a one day history of fever, chills, and significant generalised abdominal pain and tenderness. Which one of the following is likely to be the cause?

Quiz

Question 3 / 4
A patient is admitted with extensive PR bleeding secondary to diverticulitis. Which of the following definitive management options would not be suitable?

Quiz

Question 4 / 4
Which of the following is not an indication for surgical intervention in patients with diverticulitis?

Results

Further Reading

Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis
AVOD Study Group, British Journal of Surgery

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