Diverticulosis

Aka: Diverticulosis, Diverticular Disease, Diverticuli, Diverticulum, Diverticula, Colonic Diverticuli

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II. Definitions

  1. Diverticulum (Diverticula, Diverticuli)
    1. Small pouch or sac that bulges from the wall of a hollow organ (e.g. Colonic Diverticuli)
  2. Diverticulosis
    1. Colonic Diverticula present on Colonoscopy or imaging
  3. Acute Diverticulitis
    1. Inflammation of a Diverticulum

III. Epidemiology

  1. Attributed to the low fiber diets in developed countries
    1. Rare in non-developed countries, where fiber intake is higher
  2. Diverticulosis Prevalence
    1. Age over 40 years: 10%
    2. Age over 60 years: 50%
    3. Age over 80 years: 50 to 70%

IV. Pathophysiology

  1. Low fiber diet predisposes to small stools, straining and increased bowel luminal pressures
  2. Characteristics
    1. Colonic Muscle wall is weak where vessels penetrate
      1. Large Bowel submucosa Herniates through the bowel's muscular layer
      2. Diverticuli develop with patient's age
    2. Usually multiple Diverticuli present
    3. Size: Usually <10 mm
  3. Distribution
    1. Sigmoid colon
      1. Most common site for Diverticuli in western societies (accounts for 85% of Diverticuli)
    2. Ascending colon (right Diverticuli)
      1. Age <60 years
      2. Asian patients
  4. Protective factors
    1. Vegetarian Diet
    2. High fiber diet

V. Symptoms

  1. Asymptomatic in 85% of patients
  2. Colicky Abdominal Pain without inflammation in 15%
    1. Relieved with Bowel Movement or Flatus
    2. Worse with eating
    3. Associated with bloating and Constipation
    4. Left lower abdominal tenderness to palpation
  3. Diverticulitis develops in 5% of patients

VI. Differential Diagnosis

  1. Irritable Bowel Syndrome
  2. Colon Cancer
  3. Inflammatory Bowel Disease
  4. Incarcerated Hernia
  5. Mesenteric Ischemia

VII. Diagnosis: Symptomatic Diverticular Disease

  1. Colonoscopy is test of choice
    1. Rules out Colon Cancer
    2. Contraindicated in active Diverticulitis

VIII. Management

  1. High fiber diet
  2. Avoid high residue foods (seeds, nuts, corn)
    1. Recommended theoretically to prevent lodging in tics, but has been dispelled as a risk factor
    2. No evidence to support this
  3. Antispasmodic agents have no evidence to support use

IX. Complications

  1. Diverticulitis
    1. Incidence 1.5 to 6 per 1000 person years for those with Diverticula
    2. Affects 1 to 4% (up to >10% in some studies) of patients with Diverticular Disease (lifetime risk)
  2. Diverticular Hemorrhage
    1. Incidence 0.46 per 1000 person years for those with Diverticula
    2. Most common cause of Lower Gastrointestinal Bleeding

X. References

  1. Kleinmann (2023) Crit Dis Emerg Med 37(2): 22-9
  2. Bailey (2022) Am Fam Physician 106(2): 150-6 [PubMed]
  3. Rustom (2018) Inflamm Intest Dis 3(2): 69-74 [PubMed]
  4. Salzman (2005) Am Fam Physician 72:1229-42 [PubMed]
  5. Stollman (1999) Am J Gastroenterol 94:3110-21 [PubMed]

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