Diverticulosis

 

What is diverticulosis?

A diverticulum (singular) is an out-pouching of the wall of the gastrointestinal tract to form a sac.  Diverticula (plural) may occur at any level involving the esophagus, stomach, small bowel and large bowel (colon).  The diverticula discussed herein are colonic diverticula.  Diverticulosis means there are pockets or projections extending out from the wall of the colon.  These occur very gradually over a long period of time and are, therefore, more common in the elderly.  They occur along naturally weak points in the bowel wall which often coincide with perforating blood vessels bringing blood to the inner lining of the colon. 

 

The pockets develop because of the pressure exerted within the contracting colon.  Since the sigmoid colon has the highest pressure in the colon, it is here that most diverticula occur.  Because of these balloon-like projections and high pressures, the sigmoid often becomes thickened and narrowed over time just as any other muscle working overtime would become thickened.  This narrowing can cause significant changes in bowel function such as discomfort, diarrhea and/or constipation. 

 

Who gets diverticulosis?

We are all born without colonic diverticula.  Since it takes so long to develop, diverticulosis usually appears later in life.  It is not uncommon, however, to see people who have diverticulosis in their 30s or 40s.  Generally, 50% of men and women over the age of 60 develop at least one, usually a few dozen, diverticula.  Eventually the colon, especially the sigmoid colon, becomes studded with these pockets.  This disorder is mostly one of western society and is generally attributable to a diet low in fiber.  These small out pouchings are much less common in life-long vegetarians.  Diverticulosis is uncommon in rural Africa, India and many parts of Asia where diets consist largely of unprocessed foods, grains and have a very high fiber content. 

 

What are the symptoms of diverticulosis?

The vast majority of diverticula are asymptomatic.  They are frequently seen in normal people undergoing screening for colorectal carcinoma.  Approximately 10% of people may develop symptoms from their diverticula.  Non-specific lower abdominal discomfort, bloating, flatulence and erratic bowel function are common in people with normal colon and irritable bowel.  These complaints may also be seen in individuals with diverticulosis.  It is difficult to say in a patient with uncomplicated diverticulosis whether there is any relationship of the symptoms to the presence of these out-pouchings or pockets.  Fortunately, most symptoms will respond to a slow increase in fiber (up to 20 to 30 grams daily if possible), an increase in fluid intake and a decrease in dietary fat.

 

How can my doctor tell if I have diverticulosis?

Several tests can show if you have diverticulosis.  These include barium enema, flexible sigmoidoscopy, colonoscopy, and CT scanning.  Often the condition is found when tests are ordered for a different problem.  Frequently diverticular disease may be noted as an incidental or chance finding.

 

What can I expect if I have diverticulosis?

Most people with diverticulosis have no symptoms.  About 1 in every 4 people with diverticulosis develops a complication such as diverticulitis or diverticular bleeding.  Less common complications include obstruction, perforation, abscess and fistula formation.  Complications may require medical therapy treatable at home or, if severe, require hospitalization.  Depending on your condition, surgery may be recommended.

 

Caring for Diverticulosis

 

How can I take care of myself if I have diverticulosis?

1.          See your doctor and follow his treatment plan.  Maintain a diet high in fiber, avoiding nuts (peanuts), seeds (sesame, raisins) and kernel corn (popcorn, corn on the cob).  You may use a source of heat such as a hot water bottle or heating pad for abdominal cramps.  If you have diarrhea drink liquids and avoid solid foods.  Rest until the diarrhea stops and your symptoms are gone.  You may then begin low fiber foods at first and return to normal eating gradually.  Seek medical attention early.

2.        Take all of the medicine prescribed by your physician.  If you stop taking medication like antibiotics when your symptoms are gone but before the scheduled end of treatment, the symptoms may return or worsen.  If your symptoms worsen (fever, chills, acute abdominal pain, nausea, vomiting, worsening weakness, fatigue or any acute change in your condition) contact your physician or go to the emergency room immediately.

 

What is the treatment for diverticulosis?

Once a person has been diagnosed with diverticulosis the pockets will not go away unless surgically removed during colon resection.  Diverticulosis may be preventable.  A diet high in fiber, bran or roughage may be helpful in avoiding the production of diverticula.  Certain types of fiber such as wheat bran retain large quantities of water.  This, in turn, provides a bulkier stool.  Large soft stools may decrease the pressure in the bowel over time and reduce the potential for diverticula formation.  Non-prescription bulking agents are available such as Metamucil, Citrucel, Benefiber, and others.  Generic names for some of these products are Psyllium and Methylcellulose.  Bran and fiber can be found in very palatable forms such as cereals, breads and other foods.  Generally a daily intake of 20-30 grams of fiber is recommended beginning at a young age.  Importantly, if one develops diverticulitis (infection of the colon) then a low fiber diet is preferred until the infection is cleared. 

Stress can increase spasms of the colon and perhaps result in the formation of diverticula.  Stress should be controlled and treated if necessary.  Also, medications can be used to reduce spasm within the colon.  Surgery may be needed to remove the diseased portion of the colon when diverticulitis occurs at an early age or when patients experience recurrent episodes.  Surgery may also be indicated for various complications such as bleeding perforation or obstruction.

 

When is surgery necessary for the treatment of diverticular disease?

If attacks are severe or frequent or unresponsive to antibiotics and medical treatment, your doctor may advise surgery.  Your surgeon will remove the affected part of the colon and join the remaining ends.  This is called “partial colon resection with reanastomosis.”  Colon resection can be performed laparoscopically or via the standard open method called laparotomy.  It is aimed at keeping diverticular attacks from coming back and to prevent complications.  Surgery is recommended for complications such as infection, fistula, bleeding, perforation or intestinal obstruction.

Emergency surgery may result in the need for two operations or staged procedures.  The first surgery will clean the infected abdominal cavity and remove the infected colon.  Because of infection and sometimes obstruction, it may not be safe to reconnect the colon during this first operation.  Instead, the surgeon may create a temporary hole or stoma where the colon is connected to the abdominal wall as a colostomy.  The colon stoma is covered by a colostomy bag attached to the abdominal wall.  This allows for normal eating and bowel movements, where the stool now collects into a bag which can periodically be emptied.  After a period of recovery (usually many months) from the initial surgery, a second operation can be performed to rejoin (reanastomose) the ends of the colon.  This is often called a “take-down” of a colostomy or colostomy reduction, which reestablishes the normal passage of stool through the rectum. 

 

Diverticula

What causes colonic diverticula?

Most diverticula occur in the left colon, but they can also occur most anywhere except in the rectum. The common theory is that relatively high pressure is generated within the colon by muscular contractions which force the inner colon lining to penetrate outward through the path of a small blood vessel causing the colon wall to bulge or pocket on the outside of the colon. The sigmoid colon has the specialized job of contracting vigorously to maintain a high pressure which regulates the movement of stool into the rectum. Since the sigmoid colon is the high-pressure part of the colon, it is here that most diverticula occur. Low dietary fiber results in small stools and an undistended colon may generate more pressure within the colon. Whatever the cause, the incidental discovery of colonic diverticula by barium enema, x-ray, colonoscopy or surgery is usually of little significance. 

 

Although not proven, the dominant theory is that a low fiber diet is the main cause of diverticular disease. Diverticular disease is common in developed or industrialized countries such as the United States, England and Australia where low fiber diets are common. The disease is rare in countries such as Asia and Africa where people eat high fiber vegetable diets. Fiber is the part of fruits, vegetables and grains that the body cannot digest. Some fiber dissolves easily in water (soluble fiber). It takes on a soft, jelly-like texture in the intestines. Some fiber passes almost unchanged through the intestines (insoluble fiber). Both kinds of fiber help make stool soft and easy to pass. Fiber also prevents constipation and can regulate bowel movements. Constipation makes the colon muscle strain to move stool that is too hard. It is the main cause of increased pressure in the colon and cause pain and difficult bowel movements. This excess pressure might cause the weak spots in the colon (often where a blood vessel penetrates the wall) to bulge out and become diverticula. 

 

What should you do about your colon diverticula?

Most patients have few or no symptoms of their diverticulosis. However, most physicians recommend a diet high in fiber and the use of bran or psyllium supplements. It is believed that a lack of fiber causes diverticulosis and that treatment with fiber may prevent complications. While it is controversial whether or not nuts, seeds or kernel corn lodged within a diverticulum can provoke diverticulitis, most physicians recommend their avoidance or moderation. Popcorn can be a particularly high risk food to eat for patients with diverticulosis.

Your best resource to learn about diverticulosis is your physician. In addition to this web site, you can obtain information from the American Society of Colon and Rectal Surgeons (www.fascrs.org) and the National Institute of Diabetes and Digestive and Kidney Diseases (www.niddk.nih.gov). You may also go to the links pages on our CSA web site for additional educational websites such as Mayo Clinic, etc.

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Do diverticula cause symptoms?

Most individuals with colonic diverticular are unaware of them. Indeed, the usual method of discovery is by chance. There is no evidence that diverticula themselves cause any symptoms. However, other coexisting factors such as irritable bowel syndrome, colonic spasm, inflammation, etc. may result in symptoms.

As diverticula form, few symptoms are noticeable except for perhaps intermittent spastic discomfort in the lower left abdomen. Usually there are no symptoms at all. When diverticulosis is far advanced, the lower colon thickens and may become very fixed, distorted and even narrowed. When this occurs there may be thin or pellet shaped stools, constipation or an occasional rush of diarrhea. The problem then becomes a mechanical or structural one and treatment is more difficult.

Diverticulitis

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What is diverticulitis?

Diverticulitis is said to exist when a diverticulum becomes inflamed or infected.  This can be the result of a small tear or break in the lining of the colon allowing the bacteria-rich feces to penetrate the colon wall or abdominal cavity.  Diverticulitis can be mild, severe or life threatening.  It may be confined to the colon or involve the entire abdominal cavity causing peritonitis.  Peritonitis is characterized by severe abdominal pain, fever and abdominal tenderness.

 

Like a balloon, as a diverticulum expands, it develops a thin wall compared with the rest of the colon.  The colon is home to many beneficial bacteria – helpful as long as they stay in the colon.  However, these bacteria can seep through the thin wall of diverticulum and cause infection.  Some authorities believe this happens more frequently in patients who eat nuts, seeds and kernel corn (especially popcorn).  The infection within diverticula is called diverticulitis.  It can be mild with only slight discomfort in the left lower abdomen or it can be quite extreme with severe abdominal pain, tenderness and fever.  Treatment for diverticulitis includes antibiotics, bowel rest, and avoidance of solid foods.  In severe cases patients must be hospitalized and may require surgery.

 

How is diverticulitis diagnosed?

The medical history is the physician’s most important tool in diagnosing diverticulitis.  Physical examination often reveals tenderness in the left lower abdomen.  Laboratory studies often show an elevated white blood cell count.  Depending on the circumstances, diverticulitis may be diagnosed using a CT scan, barium enema, flexible sigmoidoscopy or colonoscopy.  

 

What are the symptoms of diverticulitis?

The most common symptom of diverticulitis is abdominal pain.  The most common sign is tenderness around the left lower part of the abdomen.  Some patients experience alternating diarrhea and constipation.  If infection is the cause, then fever, nausea, vomiting, chills, cramping and constipation may occur as well.  The severity of symptoms depends on the extent of infection or the presence of complications. 

 

How can I prevent recurrence of my diverticulitis?

Follow your physician’s prescribed treatments for diverticulitis and diverticulosis.  Eat regular, nutritious meals containing high fiber foods such as fruits and vegetables (unless experiencing acute diverticulitis when all solid foods including high fiber are avoided).  Drink plenty of water, low-sugar or sports drinks, as much as 8 glasses a day.  Watch for a change in bowel habits.  Get plenty of rest and sleep.  Do not eat undigestible nuts, seeds or kernel corn (especially popcorn).  These may get stuck in diverticulum and cause inflammation.  If you develop diverticulitis, you will often be placed on a fiber restricted or liquid diet and antibiotics until the infection resolves.  Contact your physician if symptoms worsen

Complications of Diverticular Disease

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What are the complications of diverticulosis?

Diverticulosis is a condition in which multiple diverticulum or “pockets” are present in the colon. While often no symptoms are present and, therefore, termed uncomplicated diverticular disease, occasionally they can become a source of serious illness. These complications of diverticulosis include active infection (diverticulitis) bleeding, perforation, abscess formation, and less commonly fistula formation and obstruction. 

It is somewhat remarkable that so few people have complications of diverticulosis when compared with the number of people who have the condition. Still, complications do occur and can be serious.

 

How can diverticulosis cause intestinal obstruction?

The scarring caused by healing of recurrent infection within diverticula may cause partial or total blockage of the large intestine. When this happens the colon is unable to move bowel contents normally. When the obstruction totally blocks the intestine, emergency surgery is necessary. Partial blockage, while not an emergency, may require surgery as well. These operations may or may not require a colostomy, where bowel contents empty into a bag attached to the abdominal wall.

 

What is a diverticular abscess?

Sometimes diverticulitis infection fails to be localized within the colon wall and breaks through the wall creating a pocket of infection called an abscess. This is usually filled with purulent fluid (pus) that must be drained. Patients are often very ill and require hospitalization and invasive radiologic or surgical procedures to drain the abscess. In very severe cases, the colon stream is diverted to the skin while the intestinal contents are temporarily collected in a colostomy bag. The infected colon is removed and later reconnected after months of recovery. Rarely, there may be free perforation of intestinal contents into the peritoneal cavity with stool soiling vital abdominal organs. The resulting peritonitis is life threatening and requires emergency surgery.

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What about perforation of diverticulum?

Perforation is the most uncommon but also the most serious complication of diverticular disease. Bacteria and/or feces that escape into the abdominal cavity cause peritonitis. This is a life threatening condition for which emergency abdominal surgery is required. Occasionally the perforation will be confined to a small area and develop into an abscess or “pus pocket.” Perforations can also result in an abnormal communication (called a fistula) between the colon and adjacent organs such as small bowel, bladder or vagina. 

 

What is a diverticular fistula?

A fistula is an abnormal connection between two organs. When damaged tissues come into contact with each other during infection, they sometimes adhere together. As they heal an abnormal connection or fistula forms. When diverticulitis-related infection spreads outside the colon, the colon’s tissue may adhere and become attached to nearby tissues. The organs usually involved in creating a colonic diverticular fistula are the bladder, small intestine, skin or vagina. The most common type of fistula occurs between the bladder and the colon. This type of fistula can result in severe, recurrent or long-lasting infection of the urinary tract. Eventually patients may experience an unusual sensation that air is being passed during urination (pneumaturia). The problem can be corrected with surgery to remove the fistula and infected portion of the colon.

 

What causes diverticular bleeding (hemorrhage)?

Diverticula tend to follow the paths of arteries as they penetrate the muscle layer of the colon wall. It is possible for these same arteries to erode through a thin wall of a diverticulum causing a major bleeding (hemorrhage) episode. At times bleeding can occur rapidly from a ruptured blood vessel in diverticula. This may produce a gush of blood from the rectum or occasionally darker mahogany or black (melena) colored stools when the bleeding is from a diverticulum in the right colon. Some authorities believe this is more common in patients who ingest nuts, seeds and kernel corn (especially popcorn). Usually the bleeding is painless but can cause weakness or fainting. This usually occurs in elderly persons and is painless. Such a serious complication requires hospitalization and blood transfusions. Fortunately, the bleeding usually stops spontaneously with bed rest and bowel rest but in about one quarter bleeding recurs. Colonoscopy is sometimes attempted to localize the site of bleeding but can be technically difficult. Angiography (injecting contrast dye into blood vessels) can be done and chemicals infused to attempt to stop the bleed. Occasionally a surgeon must operate to remove the segment of colon containing the bleeding diverticulum. In some circumstances the entire colon may have to be removed.

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How is diverticular bleeding managed?

Massive bleeding from diverticulosis is not an unusual occurrence in the elderly population. Hemorrhage most frequently occurs from right-sided diverticula. Usually bleeding results from blood vessel damage or ruptures at the neck of a diverticulum. Some authorities believe this is worsened by the ingestion of nuts, seeds and kernel corn (especially popcorn). The bleeding is often painless brisk and sudden in onset. The stool is often maroon or red depending on the severity of the hemorrhage and the time it takes to move through the colon. The treatment is bed rest, bowel rest, hospitalization for intravenous fluids and possibly blood transfusions if necessary. Fortunately, most diverticular bleeding stops spontaneously but in some cases, surgery is required. Testing is sometimes necessary to exclude other causes of bleeding such as abnormal blood vessels (angiodysplasias or arterial venous malformations) of the colon, Inflammatory Bowel Disease (ulcerative colitis or Crohn’s disease), colorectal carcinoma, or ischemic (poor circulation) colitis. Once a patient is stabilized, a bowel preparation is completed and colonoscopy may be performed. If a specific bleeding diverticula can be found, injecting a chemical named Epinephrine around the neck of the diverticulum may help stop the hemorrhage. If colonoscopy cannot be done or is not helpful, nuclear scanning techniques using radioactive labeled red blood cells, may be able to find the site of bleeding. For massive bleeding, emergency angiography (injection of dye into colon blood vessels) may be considered. Infusion of vasoconstrictors (chemical that reduce blood vessel flow) may slow or stop diverticular bleeding. This is usually only temporary. Rarely embolization (injection of a substance to block blood flow) is used to stop diverticular bleeding. These invasive angiography techniques are best reserved for those who are not surgical candidates, as they may result in damage or death of the bowel. Surgery is the treatment of choice for most life threatening diverticular hemorrhages.

High Fiber Diet

 

The simplest way to increase the fiber in your diet is to eat more fresh fruits, fresh vegetables and whole grain products.  This means eating fruits and vegetables every day.  Raw fruits and vegetables are best, but cooked, canned or dried fruits and vegetables are also helpful.  Whole grains are easiest to eat as cereals such as 100% bran or shredded wheat cereals.  Bran, oats or whole-wheat flour may be baked into breads or muffins.  You might sprinkle bran flakes on to other foods such as salads, yogurt or cereal.  If, for some reason, you cannot eat enough high fiber foods you may wish to obtain fiber from other sources.  For example, you can get psyllium seed products such as Metamucil or its generic brand from the grocery or drug store.  Cellulose is available as Citrucel.  Numerous over the counter fiber products are available in various forms such as powders, tablets, capsules, wafers and cookies.  Keep trying these various products until you find those that are effective, tastier and easier to eat.  The goal is to regularly pass a formed, soft stool without straining.

 

Amount of Fiber in Common Foods

  

       Fruits                                                         Serving Size

        Apple, raw, with skin                                  1 medium = 3.3 grams

        Peach, raw                                                1 medium = 1.5 grams

        Pear, raw                                                   1 medium = 5.1 grams

        Tangerine, raw                                          1 medium = 1.9 grams

 

       Vegetables

        Asparagus, fresh, cooked                           4 spears = 1.2 grams

        Broccoli, fresh, cooked                               ½ cup = 2.6 grams

        Brussels sprouts, fresh, cooked                  ½ cup =  2 grams

        Cabbage, fresh, cooked                              ½ cup = 1.5 grams

        Carrot, fresh, cooked                                  ½ cup = 2.3 grams

        Cauliflower, fresh, cooked                           ½ cup = 1.7 grams

        Romaine lettuce                                          1 cup = 1.2 grams

        Spinach, fresh, cooked                               ½ cup = 2.2 grams

        Summer squash, cooked                             1 cup = 2.5 grams

        Tomato, raw                                                1 = 1 gram

        Winter squash, cooked                                1 cup = 5.7 grams

 

      Starchy Vegetables

       Baked beans, canned, plain                         ½ cup = 6.3 grams

       Kidney beans, fresh, cooked                        ½ cup = 5.7 grams

       Lima beans, fresh, cooked                            ½ cup = 6.6 grams

       Potato, fresh, cooked                                   1 cup = 2.3 grams

 

      Grains

        Bread, whole-wheat                                    1 slice = 1.9 grams

        Brown rice, cooked                                     1 cup = 3.5 grams

        Cereal, bran flake                                        ¾ cup = 5.3 grams

        Oatmeal, plain, cooked                                ¾ cup = 3 grams

        White rice, cooked                                      1 cup = 0.6 gram

 

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Diverticulosis Brochure

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Diverticulosis and Diverticulitis Brochure

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