Diverticular Disease

What Is Diverticular Disease?

Diverticular disease is a condition in which small pouches, called diverticula, develop in the wall of the colon, or large intestine.

The pouches develop at weak spots in the wall of the colon. These weak spots occur because of excess pressure in the colon, or existing weakness in the colon wall, that eventually bulge out to form pouches.

The increase in pressure in the colon is commonly caused by constipation due to lack of fiber in the diet.

Most pouches occur in the sigmoid colon-the lower left part of the large intestine that connects to the rectum.

The condition is common in older people, affecting about half of Americans by age 60 and nearly all by age 80. Only a small percentage of those with diverticula will have symptoms.

In a small number of people who develop diverticula, the diverticula become inflamed or infected. This condition is known as diverticulitis.

Diverticular disease was virtually unheard of before a hundred years ago. It has become common in western countries-especially the United States, England, and Australia-where the average diet consists of processed foods that are low in fiber.

The change in the way wheat was processed into flour at the turn of the century-from a crushing to a finer rolling process-accounts substantially for the depletion of fiber in our diets.

The condition is far less widespread in Asian and African countries, where diets still include large amounts of fiber. However, with economic development and changes in diet, the incidence of diverticular disease is increasing in African countries.

For further information about fiber, go to Fiber: Its Importance In Your Diet.

What Causes Diverticular Disease?

Diverticular disease essentially results from eating a diet with too little fiber.

Fiber itself is not digested. It passes through the intestines pretty much unchanged, softening the stools and their passage. Lack of fiber begins a sequence of events:

• Without fiber, the stools are dry and small, and the intestinal muscles must contract with greater force to pass the stools along, generating a higher pressure in the large intestines.
• The excess pressure leads to weak spots in the colon walls that eventually bulge out and form pouches called diverticula.
• Existing weakness in the colon walls-either from age or, in younger people, or from collagen disorders like Marfan’s syndrome-also contribute to the development of diverticula.
• Most often, the pouches form in the sigmoid colon, which is the lower left part of the colon that connects to the rectum. This area of the colon is subject to the highest amount of pressure because it is the narrowest portion of the large intestine.

No treatment has been found to prevent diverticular disease from developing. And, once formed, diverticula are permanent.

But a diet high in fiber increases stool bulk and prevents constipation, and experts believe it may:

• Help keep more diverticula from forming
• Help keep the condition from worsening

Who Is At Higher Risk?

You more likely to develop diverticular disease if:

• your diet is low in fiber
• you have a family history of diverticular disease
• you are over age 50
• you are obese
• you use laxatives on a regular basis

What Are The Symptoms Of Diverticular Disease?

Most people with diverticular disease never experience symptoms.

When symptoms do appear, they range widely in severity, depending on the extent of the inflammation or infection of the pouches, and the possible complications that may occur.

The most common symptoms are:

• Pain in the abdomen, usually on the lower left side, ranging from slight tenderness to severe pain
• Cramps and bloating
• Muscle spasms
• Diarrhea or constipation
• Bleeding with the stools

If infection develops in a pouch (diverticulitis), a person may also experience:

• Fever or chills
• Nausea
• Vomiting
• The release of pus and mucus from the rectum

Other Conditions With Similar Symptoms

It is important to see a doctor if you experience any of the symptoms of diverticular disease, in order to identify the cause. There are several other conditions that may present similar symptoms:

• Irritable bowel syndrome
• Appendicitis (typically causes pain on the lower right side of the abdomen, distinguished from diverticular disease where pain is experienced usually on the lower left side)
• Stomach ulcers
• Colon or bowel cancer
• Ulcerative colitis, an inflammatory condition of the colon
• The presence of a foreign body in the intestines
• Hemorrhoids
• Fibroid tumors in women (noncancerous tumors of the uterus)

For further information about colorectal cancer, go to Colorectal Cancer.

For further information about ulcerative colitis, go to Ulcerative Colitis.

For further information about Fibroids, go to Fibroids.

How Is Diverticular Disease Diagnosed?

Since a wide range of conditions produces symptoms that are similar to those of diverticular disease, diagnosis can be complicated. In addition to taking a medical history and performing a physical exam, tests may be required for a definitive diagnosis.

Medical History And Physical Exam

A doctor may suspect that a person has diverticular disease based on answers to questions about bowel habits, pain, symptoms, and diet.

The doctor may gently press on the abdomen to check for tenderness or for the existence of a mass in the intestinal area. A rectal exam will likely be performed to detect tenderness, blood, or a blockage in the rectum. A stool sample may also be checked for signs of blood.

Diagnostic Tests

The following tests are used to diagnose diverticular disease:

• Barium enema and x-rays, which involves x-rays of the colon using a contrast medium (barium), which is introduced into the rectum by enema and is visible on the x-rays. The barium fills the pouches, making them easy to see on the x-ray.
• Sigmoidoscopy, which involves the use of a thin, flexible, lighted instrument that is inserted through the rectum to examine the interior of the rectum and sigmoid colon.
• Colonoscopy, which involves the use of a flexible, lighted instrument inserted through the rectum to examine the interior of the rectum and entire colon – a more extensive examination than a sigmoidoscopy.

What Are The Complications From Diverticular Disease?

People generally remain unaware that they have diverticular disease unless a complication arises. Complications typically start when one or more of the pouches, or diverticula, become infected and inflamed and diverticulitis develops.

Symptoms from complications can come on quite suddenly and include:

• Bleeding from the rectum
• Abscess
• Perforation
• Peritonitis
• Intestinal obstruction
• Fistula

Bleeding From The Rectum

Small blood vessels can be particularly fragile in inflamed diverticula. They can become so stretched that they weaken and finally burst, releasing a surge of blood. The blood may appear in the stool or in the toilet. The bleeding may stop spontaneously and not require treatment. If it continues, it may require surgery.

Abscess

If an infected diverticulum (a single diverticula) cannot be treated successfully with antibiotics, an abscess may develop. An abscess is a collection of pus surrounded by inflamed tissue. The abscess may go away if the person takes antibiotics, or it may deteriorate and burst, causing peritonitis, a life-threatening infection in the abdominal cavity.

Perforation

Sometimes an inflamed diverticulum perforates (tears). The risk of perforation is particularly high after a diverticulum becomes seriously infected and develops an abscess. Pus from the abscess can leak out from the intestinal walls into surrounding cavities.

Peritonitis

Once an infection leaks out of the intestinal walls through a perforated (torn) diverticulum, it can lead to peritonitis, a life-threatening infection in the abdominal cavity.

Intestinal Obstruction

Infection from diverticular disease can cause enough thickening and scarring of the bowel wall to block the large intestine, constricting the movement of bowel contents. A complete obstruction requires emergency surgery.

Fistula

A fistula is an abnormal connection between two organs. This can arise when inflamed or damaged tissue sticks to another organ and heals that way. For example, an infected diverticulum may attach to organs such as the bladder or small intestine. Often in men, a fistula forms between the colon and the bladder. This can lead to a severe urinary tract infection. (In women, the uterus normally blocks the colon’s path to the bladder.)

How Is Diverticular Disease Treated?

Many people with diverticular disease have no symptoms and require no treatment. Treatment is required if symptoms develop.

Usually symptoms can be treated successfully, and most people who have an episode of inflamed diverticular disease do not suffer a recurrence.

If serious complications do develop, surgery may be required to remove the affected parts of the colon. But few people with the disease require surgery.

Treatment of diverticular disease may include:

• Treating acute symptoms
• Maintaining fiber in the diet
• Treating serious complications
• Surgery

Treating Acute Symptoms

When diverticula become inflamed, causing symptoms such as pain, fever, and chills, a doctor will typically prescribe antibiotics and a liquid diet until symptoms subside.

Hospitalization may be necessary if an infection is severe or if a person feels intense pain. In the hospital, the patient receives antibiotics and fluids through a vein. Antibiotics can usually cure an infection in a few days if there are no further complications.

Maintaining Fiber In The Diet

Usually, all that is prescribed once the initial inflammation passes is a high-fiber diet. A doctor may also suggest the use of stool softeners and mild pain medications

Treating Serious Complications

Serious complications require immediate surgery. Complications that are slightly less severe can usually be treated with planned surgery or other interventions.

• Bleeding from the rectum – Often, bleeding from the rectum stops soon after it starts. But if it does not, a colonoscopy may help avoid surgery. A long, flexible device with a light on the end is maneuvered through the colon to find the bleeding diverticula. At the same time, drugs or cautery devices (which burn wounds shut) can be introduced into the colon to stop the bleeding.
• Abscess – Antibiotics will usually clear up most small abscesses. Larger ones may need to be drained. A doctor will insert a thin tube (a catheter) through the skin and into the abscess to drain it. If the abscess cannot be drained successfully, surgery may be necessary to clean away the abscess or, in severe cases, remove part of the colon.
• Perforations and peritonitis – Peritonitis, an infection of the lining of the abdomen caused by a perforation (tear) in the colon, can be fatal. Immediate surgery is required to clean the infected parts of the abdomen and remove the perforated part of the colon.
• Intestinal obstruction – When scarred tissue blocks the intestine, surgery is required to clear the blockage.
• Fistula – The most common kind of fistula (an abnormal connection between two organs) is between the colon and bladder in men. This is corrected with surgery. The connection is freed and the damaged part of the colon is removed.

Surgery

When doctors perform surgery on patients with diverticular disease, they typically remove the diseased part of the colon and reattach the remaining sections back together. This procedure is called resection.

Sometimes, resection will involve two operations:

1. In the first, surgeons remove the diseased part of the colon and perform a colostomy, a procedure in which part of the colon is attached to the skin through a temporary opening made in the abdominal wall. A bag is attached to the skin to drain the stool.
2. After the infection clears up, the cut ends of the colon are reattached together in a second operation, and normal bowel function is restored. The hole in the skin is surgically closed and will heal.

Living With Diverticular Disease

Living with diverticular disease involves:

• A high-fiber diet
• Treating mild symptoms

A High-Fiber Diet

Usually the simple remedy of a high-fiber diet may well prevent the development of complications from diverticular disease. People hospitalized for complications of diverticular disease typically start a high-fiber diet while still in the hospital.

Fiber keeps stool soft, keeps the contents of the intestines moving, and lowers the pressure in the colon. So fiber decreases the likelihood that new diverticula will form or that diverticula that are already present will become infected and inflamed.

A good diet should contain approximately 25 to 30 grams of fiber a day. The average American eats less than half of that. The following are good sources of fiber:

• Whole grains (bran has the highest fiber content, about 25 to 45 percent)
• Nuts and seeds
• Legumes
• Fruits
• Vegetables
• A dietary supplement of fiber products such as Citrucel orMetamucil

Studies have shown that a high-fiber diet has widespread health benefits. And unlike many other treatments, fiber in the diet has no danger of adverse reactions, toxicity, or dangerous side effects.

For further information about fiber, go to Fiber: Its Importance In Your Diet.

Treating Mild Symptoms

For mild symptoms:

• To relieve cramps, a source of heat, such as a hot water bottle, can help. If the cramps are more severe, the doctor may prescribe pain medication.
• To treat diarrhea, drink plenty of liquids, avoid solid foods, and rest until the diarrhea stops. Eat bland, low-fiber foods to start. Gradually return to a varied, high-fiber diet.
• To control muscle spasms in the colon, medication such as Pro-Banthine (Propantheline), which is an anti-spasmodic, are prescribed.

When symptoms first arise, or if they worsen or recur, it’s important to see a doctor and follow the prescribed treatment.

What Is The Outlook For Diverticular Disease?

The large majority of people with diverticular disease will not realize they have diverticula unless the condition is discovered during a colonoscopy. You can reduce your risk for the disease or its complications by eating plenty of fiber.

Those who do experience discomfort usually suffer a relatively mild case of inflammation, readily treated with antibiotics in the short term and a high-fiber diet in the long term.

As many as 90 percent of people with diverticula will never experience symptoms.

Diverticular Disease: Frequently Asked Questions

Here are some frequently asked questions related to Diverticular Disease.

Q: Does diverticular disease increase the chance of later developing colon cancer?

A: No, diverticular disease doesn’t seem to increase the risk for colon cancer. But the symptoms of colon cancer can be quite similar to those of diverticular disease. Cancer and diverticula often look alike on CT scans (CT stands for Computed Tomography, a type of x-ray that shows the condition of soft tissue). So anyone suspected of having diverticular disease based on the findings of a CT scan should have a colonoscopy to rule out colon cancer. If no cancer is found, people with diverticular disease should undergo the same schedule of colon cancer screening as the general population.

Q: I’ve increased the amount of fruits and vegetables in my diet, but should I avoid foods with seeds, for fear that the seeds may become trapped in diverticula and cause irritation?

A: In the past, doctors recommended that people with diverticular disease avoid eating seeds, like those in cucumbers and strawberries. But there’s no scientific evidence supporting the notion that the particles become lodged in diverticula and inflame them. Some doctors still recommend that their patients eat foods with seeds in moderation.

Q: Do I have to get my fiber from food? Is taking a fiber supplement enough?

A: Supplements provide only a very restricted type of fiber, while eating a diet of high-fiber foods usually incorporates various kinds of fiber, and that’s healthier. Fruits, vegetables, and oats have plenty of soluble fiber. Whole grains, bran, legumes, and many fruits and vegetables are full of insoluble fiber. Both soluble and insoluble fiber add bulk and softness to the stool. Insoluble fiber remains pretty much unchanged by the time it reaches the intestines, whereas soluble fiber acquires a soft, jelly-like texture. Both make stools easier to pass.

Q: Exactly how much fiber should I get in my diet?

A: The American Dietetic Association recommends 20 to 35 grams of fiber each day. Your doctor may also recommend drinking a fiber product such as Citrucel or Metamucil once a day. These products are mixed with water, and each 8-ounce glass provides about four to six grams of fiber.

Q: Is diverticular disease hereditary?

A: Diverticular disease is acquired. Diverticula are very common in people who eat a diet high in fat, processed foods, and low in fiber. However, as with most diseases, there are some genetic factors to consider. People with collagen disorders are particularly prone to developing diverticular disease. For example, young people with Marfan’s syndrome, a collagen disorder, have a relatively high chance of developing the condition early in life.

Diverticular Disease: Putting It All Together

Here is a summary of the important facts and information related to Diverticular Disease.

• People with diverticular disease develop small pouches-called diverticula-in the walls of their colon.
• The diverticula develop from excess pressure in the colon that is caused by constipation due to lack of fiber in the diet.
• The condition is common in older people.
• The vast majority of those affected never develops symptoms and remains unaware that they have the condition.
• The diverticula occasionally become infected or inflamed, typically causing tenderness and pain in the lower, left side of the abdomen.
• In a small number of cases, complications can be severe and may result in a life-threatening condition, requiring emergency surgery.
• In most cases, eating a high-fiber diet is the best and only treatment required.

Diverticular Disease – Glossary

Here are definitions of medical terms related to Diverticular Disease.

Abscess: A collection of pus surrounded by damaged and inflamed tissue, usually caused by bacterial infection.

Carbohydrate: The main source of energy for all body functions, especially brain functions; major sources of carbohydrates are cereals, vegetables, fruits, rice, potatoes, legumes, and flour products.

Collagen disorders: Problems with the connective tissues of the body; collagen is a protein that strengthens the tissues in which it is imbedded.

Colon: The main part of the large intestine, responsible for absorbing water and salts from the digested products of the small intestine, and passing the digested products into the rectum for removal from the body.

Colonoscopy: Use of a flexible lighted instrument inserted through the rectum to examine the interior of the rectum and entire colon.

Colostomy: A surgical procedure in which part of the colon is attached to the skin through an opening made in the abdominal wall. A bag is attached to the skin to drain the stool.

Diverticula: Small pouches that protrude out of the normally smooth wall of the colon.

Diverticular disease: The range of conditions from diverticulosis (the asymptomatic presence of diverticula) to diverticulitis with complications.

Diverticulitis: Inflammation of one or more diverticula.

Diverticulosis: The presence of one or more diverticula.

Diverticulum: A single pouch that protrudes out of the normally smooth wall of the colon.

Fiber: The parts of plant cells that are undigested in the small intestine; fiber is important to the health of the digestive system.

Peritonitis: Inflammation of the membrane that lines the abdominal cavity.

Rectum: The terminal part of the large intestine, running from the sigmoid colon to the anus.

Sigmoid colon: The lower left part of the colon that connects to the rectum.

Sigmoidoscopy: Use of a thin flexible lighted instrument inserted through the rectum to examine the interior of the rectum and sigmoid colon.

Diverticular Disease: Additional Sources of Information

Here are some reliable sources that can provide more information on Diverticular Disease.

The National Institute of Diabetes and Digestive and Kidney Diseases, a part of the National Institutes of Health. 
http://www.niddk.nih.gov/health/digest/digest.htm

The web site posts information on digestive diseases, provides a directory of digestive diseases organizations for patients, and will send free publications and respond to specific inquiries about digestive diseases through the National Digestive Diseases Information Clearinghouse.

American Society of Colon and Rectal Surgeons 
Phone: 1-847-290-9184
http://www.fascrs.org

The American Society of Colon and Rectal Surgeons includes 1,500 surgeons; many in this professional association specialize in the research, diagnosis, and treatment of diseases of the colon and rectum. Contact them for more information or a list of local colorectal surgeons.