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Overview |
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Definition |
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Diverticula are sac-like protrusions in the wall of the colon. Rarely, they
are congenital and involve all layers of the colon wall. Pseudodiverticula, the
more common acquired form, are herniations that extend through the mucosa, the
submucosa, and into the circular muscular coat. Most diverticula occur in the
sigmoid colon (95%). The presence of many diverticula along the bowel wall is
called diverticulosis. Diverticulitis is the inflammation of one or multiple
diverticula that often results in a microperforation or macroperforation of the
bowel. It occurs in 15% to 20% of patients with diverticula. It may be a
localized inflammation or can involve free perforation or peritonitis. The
sequelae of diverticular disease (see section on Complications/Sequelae)
can be very serious and typically require surgery.
According to epidemiologic studies, diverticulitis is significantly more
common in countries with Western, low-fiber diets. Prevalence in the United
States is estimated at 10%. However, more than 50% of autopsied adults over the
age of 60 have diverticula. |
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Etiology |
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The etiology is presumed to be multifactorial but not clearly understood.
Factors potentially contributing to the initiation of changes in the colonic
wall include aging, colonic motility, abnormal changes in intraluminal pressure,
low-fiber diets, and various anatomic defects. |
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Risk Factors |
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- Low-fiber, Western diet
- Aging
- Obesity
- Men—for diverticulitis
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Signs and Symptoms |
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Diverticula
- Often asymptomatic
- Mild irregularities in defecation
Diverticulitis
- Left lower quadrant pain is classic, often following a meal; may have
abdominal pain in other locations.
- Painless rectal bleeding, hematochezia,
hemorrhage—usually from the right colon; 15% to 40% of
patients; 25% to 50% of the time, microscopic blood is found on exam.
- Fever
- Nausea, vomiting
- Constipation, diarrhea
- Flatulence
- Fistulas—urinary tract infection,
pneumaturia, dysuria, frequency
- Peritonitis—acute onset abdominal pain,
muscle spasm, guarding, possibly
sepsis
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Differential
Diagnosis |
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- Irritable bowel syndrome
- Colorectal cancer
- Inflammatory bowel disease
- Appendicitis
- Angiodysplasia
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Diagnosis |
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Physical Examination |
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Diverticulitis
- Left lower quadrant tenderness
- Abdominal distention
- Percussion tenderness, guarding—indicates
peritonitis
- Palpable mass possible
- Fever >101°F
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Laboratory Tests |
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Diverticulitis
- Complete blood cell count—white blood cells
(WBC) usually elevated (>15,000); predominance of polymorphonuclear
leukocytes
- Urinalysis—WBC predominate with inflammation
adjacent to bladder or ureter; bacteria indicate fistula.
- Stool—reveals occult blood in 25% to 50% of
cases.
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Pathology/Pathophysiology |
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- Diverticula form between mesenteric and lateral teniae, especially at
area of greatest muscular weakness where the intramural vasa recta penetrate the
circular muscle to the submucosa.
- Increased muscle layer thickening causes teniae to shorten, narrowing
the colonic lumen and permitting muscle contractions that divide the bowel into
isolated segments; hypersegmentation results in intraluminal hypertension
³90 mm Hg, causing mucosal herniation.
- Fecalith erodes or becomes impacted in the mucus lining, rendering it
susceptible to bacterial invasion and causing inflammation (localized, which can
become generalized to peritonitis).
- Healed diverticula can leave segmental narrowing, stricture, or
obstruction.
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Imaging |
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- Computed tomography—locates inflammation,
abscesses, obstruction, fistulae; assists with percutaneous abscess drainage.
- Barium enema—shows diverticula, fistulae,
abscesses; risk of generalized peritonitis limits its use during acute attack of
diverticulitis.
- Ultrasound—reveals inflammation, diverticula,
abscesses; assists with percutaneous
drainage.
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Other Diagnostic
Procedures |
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- Colonoscopy—localizes diverticula;
differentiates colorectal cancer; evaluates acute
hematochezia.
- Angiography—localizes diverticula during
profuse bleeding.
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Treatment Options |
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Treatment Strategy |
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With mild symptoms, outpatient treatment includes clear liquid diet and oral
broad-spectrum antibiotics. Inpatient treatment includes bowel rest by
administration of total parenteral nutrition and intravenous broad-spectrum
antibiotics. Patients improving within 72 hours can resume oral diet and are
discharged with oral antibiotics. High-fiber diets and psyllium supplements are
recommended following acute episode. Within 6 weeks, colonoscopy or barium enema
is performed. Elective surgery is recommended if attacks recur; generally,
surgery is performed once an acute attack has resolved. Patients under 40 (more
aggressive disease), who deteriorate within 24 to 48 hours, or those who have
severe complications, are treated urgently with surgery. |
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Drug Therapies |
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- Broad-spectrum antibiotic therapy—cefoxitin 2
to 3 g IV q8hr; metronidazole 500 mg IV q6hr with an aminoglycoside for more
severe cases; either TMP/SMX 160 mg/800 mg po bid or amoxicillin 500 mg tid or
ciprofloxacin 500 mg po bid, plus metronidazole 500 mg po q 6 hours for
outpatient
- Anticholinergics—relieve cramping, but risk
of constipation
- Analgesics—avoid narcotics if possible,
especially morphine which causes colonic spasm; meperidine use acceptable
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Surgical Procedures |
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- Colonoscopy—electrocoagulation of arterial
venous malformations or angiodysplasias; its use with epinephrine injections
and/or bipolar coagulation decreases risk of severe hemorrhage
- Sigmoidectomy—one-step operation performed
after bowel preparation; done laparoscopically in uncomplicated cases
- Hartman's procedure—commonly used for
emergency surgery; resection with sigmoid colostomy and rectal stump closure;
colostomy reversed in second operation within 6 months; lowers mortality by
reducing sepsis
- Angiography—therapy at diagnosis includes
intra-arterial infusions of vasopressin (0.2 U/min for 6 to 12 hours) or
selective embolization to temporarily control bleeding; treatment failure
associated with higher mortality because of surgical
delay
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Complementary and Alternative
Therapies |
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Nutrition plays an important role in the prevention and treatment of
gastrointestinal disease in general and development of diverticulosis in
particular. Specific dietary factors have been correlated with the incidence of
diverticular disease and may play a role in minimizing exacerbations and
improving outcome. |
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Nutrition |
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High-Fiber Diet
Epidemiological studies suggest that high dietary fiber consumption is
protective against the development of diverticular disease and other
gastrointestinal disorders. A review of epidemiological studies reports that
vegetarians have a decreased incidence of diverticular disease, most likely due
to increased intake of dietary fiber (Nair and Mayberry 1994).
An epidemiological study in Greece matched 100 consecutive patients who had
radiographically confirmed diverticular disease against 110 control patients
with no presence of diverticulosis, gastrointestinal disorders, or significant
abdominal symptoms. A structured interview and a food frequency questionnaire
were administered to all subjects. A statistically significant protective
association was found between the following foods and diverticular disease:
- Cucumber
- Lettuce
- Spinach
- Brown bread
Foods that were significantly detrimental were beef and lamb. The authors
concluded that in addition to increasing fiber intake, lowering risk of the
disease requires (Manousos et al. 1985):
- Decreasing the consumption of red meat, particularly lamb and beef
- Reducing intake of milk and milk derivatives, although not as
important as reduction of meat ingestion
Other Lifestyle Factors
While epidemiological studies link increased consumption of dietary fiber
with decreased risk of diverticular disease, there is less conclusive evidence
about the impact of other lifestyle factors. Findings from a prospective study
of 47,678 men, 40 to 75 years old, who were enrolled in the U.S. Health
Professionals Follow-Up Study showed that 500 subjects developed diagnoses of
diverticular disease during 4 years of follow-up; 382 of these were classified
as symptomatic. Investigators found little or no relationship between the
following and development of symptomatic diverticular disease:
- Smoking
- Consumption of caffeine
- Moderate alcohol intake
Although there was no overall association between smoking and diverticular
disease, smokers in the highest category
(³40 pack-years)
did have a 21% greater risk of developing the disease compared to those who had
never smoked. The authors suggest, though, that this connection may actually be
due to:
- Dietary fiber intake
- Level of physical activity
- Amount of dietary fat consumed
In other words, smoking does not appear to be an independent risk factor for
diverticulosis (Aldoori et al. 1995).
Glutamine
The relationship of specific micronutrients to diverticular disease has not
been evaluated as thoroughly as generalized dietary and lifestyle trends.
Glutamine, though, may prove beneficial in the prevention and treatment of
diverticular disease through the following mechanisms (Murray 1996):
- Prevention of colonic mucosal atrophy
- Reduced macromolecule permeability
- Inhibition of the rate of bacterial translocation to mesenteric lymph
nodes
Short-Chain Fatty Acids
Short-chain fatty acids (SCFAs) are thought to be essential for normal
colonic mucosal function:
- Butyrate
- Isobutyrate
- Propionate
- Acetate
SCFAs are not obtained through the diet but are produced by the action of
anaerobic bacteria on undigested carbohydrates (e.g., resistant starch or
dietary fiber). Certain fibers increase the levels of SCFAs produced in the
colon more effectively (Murray 1996). These dietary fiber products include:
- Apple and citrus pectin
- Guar gum
- Legumes
Butyrate, in particular, is thought to have a stabilizing effect on colonic
mucosa, serving as a respiratory fuel for colonic epithelia, and enhancing
cellular growth, proliferation, and differentiation (O'Keefe 1996).
Omega-3 Essential Fatty Acids
Omega-3 essential fatty acids found in flax and fish have anti-inflammatory
properties while omega-6 fatty acids found in meats and dairy products are
pro-inflammatory. To prevent or treat a condition such as diverticulitis, it
seems prudent to follow a diet rich in omega-3 fatty acids. Another benefit for
this nutritional plan is that studies suggest that it is a good diet for
preventing colon cancer (O'Keefe 1996). |
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Herbs |
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Certain herbs are used for the beneficial effects of their fiber content:
- Psyllium seed (Plantago ovata and Plantago psyllium) is
recommended by the World Health Organization (WHO) to relieve diverticulitar
associated constipation (Blumenthal et al. 2000).
- Flaxseed (Linum usitatissimum) is approved by the German
Commission E as part of the treatment for diverticulosis (Blumenthal et al.
2000).
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Homeopathy |
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Although there is anecdotal information about the value of homeopathy for
prevention and treatment of gastrointestinal disorders including diverticular
disease, this has not been adequately studied to date. An experienced homeopath,
though, will consider an individual's constitution and collection of symptoms
and may recommend some of the following remedies:
- Belladonna—for abdominal pain and
cramping that come on suddenly and are relieved by firm pressure; especially
with constipation
- Bryonia—for abdominal pain that is
worse with movement and is alleviated by heat; especially with vomiting,
constipation, and dry, hard stools
- Colocynthis—for cutting, cramping
abdominal pains that are better with pressure; especially when accompanied by
restlessness and
diarrhea
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Patient Monitoring |
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- Patients should report fever, tenderness, or bleeding immediately.
- Patients with fever >101°F, deterioration, signs of peritonitis, or
increased WBC count should be hospitalized for initial
treatment.
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Other
Considerations |
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Prevention |
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- High-fiber diet (15 g/day)—increases stool
weight and transit time, decreases colonic pressure
- Avoid foods (e.g., seeds) that block the mouth of the
diverticulum.
- Exercise—tends to decrease incidence of
symptoms
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Complications/Sequelae |
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- Abscess—most frequent complication
- Obstruction—can mimic neoplasm
- Free perforation—acute peritonitis, sepsis,
shock; elderly most vulnerable
- Fistulas—abscesses that erode into adjacent
organs, requires prompt control of sepsis
- Bleeding—70% stop spontaneously;
resuscitative measures and blood transfusions required before surgery
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Prognosis |
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- Diverticulitis—30% of patients have second
episodes; 50% of those having second attacks have third attacks
- Complications—20% of patients after first
attack, 60% after second attack
- Elective surgery—2% mortality rate
- Purulent peritonitis 5% mortality rate, feculent peritonitis 35%
- Risk of bleeding—50% after second
hemorrhage
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Pregnancy |
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- May need to be differentiated from ectopic pregnancy at the time of
presentation
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References |
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Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC. A
prospective study of alcohol, smoking, caffeine, and the risk of symptomatic
diverticular disease in men. Ann Epidemiol. 1995;5(3):221-228.
Ambrosetti P, Robert JH, Witzig JA, et al. Acute left colonic diverticulitis:
a prospective analysis of 226 consecutive cases. Surgery.
1994;115(5):546-550.
Blumenthal M, Goldberg A, Brinckmann J, eds. Herbal Medicine: Expanded
Commission E Monographs. Newton, Mass: Integrative Medicine Communications;
2000:134-138, 314-321.
Dambro MR. Griffith's 5 Minute Clinical Consult. Baltimore, Md:
Lippincott Williams & Wilkins, Inc.; 1999.
Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998.
Feldman M, ed. Sleisenger & Fordtran's Gastrointestinal and Liver
Disease. 6th ed. Philadelphia, Pa: W.B. Saunders; 1998.
Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J
Med. 1998;338(21):1521-1526.
Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular
disease of the colon. Adv Surg. 1978;12:85-109.
Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy for the
diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med.
2000;342(2):78-82.
Kohler L, Sauerland S, Neugebauer E. Diagnosis and treatment of the
diverticular disease: results of a consensus development conference. Surg
Endosc. 1999;13(4):430-436.
Manousos O, Day NE, Tzonou A, et al. Diet and other factors in the aetiology
of diverticulosis: an epidemiological study in Greece. Gut.
1985;26(6):544-549.
Murray M. Encyclopedia of Nutritional Supplements. Rocklin, Calif:
Prima Publishing; 1996:315.
Nair P, Mayberry JF. Vegetarianism, dietary fibre and gastro-intestinal
disease. Dig Dis. 1994;12(3):177-185.
O'Keefe SJ. Nutrition and gastrointestinal disease. Scand J Gastroenterol
Suppl. 1996;220:52-59.
Sabiston DC, Lyerly HK, eds. Textbook of Surgery. 15th ed.
Philadelphia, Pa: W.B. Saunders;
1998. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
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including any injury and/or damage to any person or property as a matter of
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The reader is advised to check product information (including package inserts)
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interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |