Introduction
Pathophysiology
Diverticula are small mucosal herniations protruding through the intestinal layers and the smooth muscle along the natural openings created by the vasa recta or nutrient vessels in the wall of the colon. These herniations create small pouches lined solely by mucosa. Diverticula can occur anywhere in the gastrointestinal tract but are usually observed in the colon. The sigmoid colon has the highest intraluminal pressures and is most commonly affected. Diverticulosis is defined as the condition of having uninflamed diverticula. The cause of diverticulosis is not yet conclusive, but it appears to be associated with a low-fiber diet, constipation, and obesity.
Diverticulitis is defined as an inflammation of one or more diverticula. Its pathogenesis remains unclear. Fecal material or undigested food particles may collect in a diverticulum, causing obstruction. This obstruction may result in distension of the diverticula secondary to mucous secretion and overgrowth of normal colonic bacteria. Vascular compromise and subsequent microperforation or macroperforation then ensue. Alternatively, some believe that increased intraluminal pressure or inspissated food particles cause erosion of the diverticular wall, resulting in inflammation, focal necrosis, and perforation. The disease is frequently mild when pericolic fat and mesentery wall off a small perforation. However, larger perforations and more extensive disease lead to abscess formation and, rarely, intestinal rupture or peritonitis.
Fistula formation is a complication of diverticulitis. Fistulas to adjacent organs and the skin may develop, especially in the presence of an abscess. In men, colovesicular fistulas are the most common. In women, the uterus is interposed between the colon and the bladder, and this complication is only seen following a hysterectomy. The uterus precludes fistula formation from the sigmoid colon to the urinary bladder. However, colovaginal and colocutaneous fistulas can form but are uncommon.
Recurrent attacks of diverticulitis can result in the formation of scar tissue, leading to narrowing and obstruction of the colonic lumen.
Frequency
United States
Asymptomatic diverticulosis is a common condition. The incidence of diverticulosis increases with age, from less than 5% before age 40 years to greater than 65% by age 85 years.
Diverticulitis appears to be more common in patients with the largest number of diverticula; 15-20% of those with diverticulosis develop diverticulitis. While diverticulitis is generally considered a disease of the elderly population, as many as 20% of patients with diverticulitis are younger than 50 years.
International
Diverticulosis occurs more frequently in Western countries and industrialized societies. As it is less common in underdeveloped countries, diverticulitis is also less common. The reason is unclear but presumably secondary to lifestyle and dietary factors. In fact, after adopting a more Western lifestyle, the prevalence of diverticulosis has increased in Japan. For unclear reasons, right-sided disease is more common in Asian people, accounting for as many as 75% of cases of diverticulitis in that group.
Mortality/Morbidity
Of patients with diverticulosis, 80-85% remain asymptomatic. Approximately 5% develop diverticulitis; 15-25% of those with diverticulitis develop complications leading to surgery. These complications include abscess formation, intestinal rupture, peritonitis, and fistula formation.
Diverticulitis may be a more severe illness in patients who are immunocompromised, in patients with significant comorbid conditions, and in those taking anti-inflammatory medications.
- Patients with diverticulitis who are managed conservatively (ie, do not receive surgery) have a recurrence rate of 20-35%.
- In one study of 252 patients, a recurrence rate of 50% was reported after 7 years. The rate of surgery in these patients was 8% at 7 years and rose to 14% by 13 years. Recurrence rates after surgical resection range from 1-3%. The mortality rate from complications in patients with recurrent disease in this small study was 1%.
- Another study of 337 patients hospitalized for complicated diverticulitis revealed an association of perforation and mortality in those with no prior history of diverticulitis. Of these patients with complicated diverticulitis, 53% presented on a first event.
- These morbidity and mortality data, as well as recurrence rates, are based on a retrospective review of relatively short-term data.
Race
Genetics are believed to play a role, in addition to dietary factors. Left-sided diverticula predominate in the United States. Asians, including Asian Americans, have a predominance of right-sided diverticula.
Sex
Prevalence is similar in men and women.
Age
Diverticular disease increases in incidence with age, reaching a prevalence of greater than 65% in those older than 85 years. The mean age at presentation with diverticulitis appears to be about 60 years.
Clinical
History
The clinical presentation of diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence of complications. Left lower quadrant pain is the most common presenting complaint and occurs in 70% of patients. Pain is often described as crampy and may be associated with a change in bowel habits. Other symptoms include nausea and vomiting, constipation, diarrhea, flatulence, and bloating. Symptoms of mild diverticulitis may be confused with overlapping symptoms of irritable bowel syndrome.
A microperforation, most likely walled off by adjacent structures, may present with no systemic signs of illness or infection. On the other hand, disease may progress from a localized and walled-off process to one with peridiverticular inflammatory phlegmon and localized abscess. Systemic signs of infection (eg, fever) then develop. Because diverticula and, hence, diverticulitis can develop anywhere in the gastrointestinal tract, symptoms may mimic multiple conditions.
- Diverticulitis in the right colon or in a redundant sigmoid colon may be mistaken for acute appendicitis. Diverticulitis in the transverse colon may mimic peptic ulcer disease, pancreatitis, or cholecystitis. Retroperitoneal involvement may present similar to renal disease. In women, lower quadrant pain may be difficult to distinguish from a gynecological process.
- More severe diverticulitis is often accompanied by anorexia, nausea, and vomiting. Typically, the pain is localized and severe and present for several days prior to presentation. Altered bowel habits, especially constipation, are reported by most patients. A small percentage of patients may complain of urinary symptoms, such as dysuria, urgency, and frequency, due to inflammation adjacent to urinary tract structures.
- Macroperforation with spillage of colonic contents into the peritoneum leads to generalized abdominal pain and peritonitis.
- Leg pain possibly associated with a thigh abscess and leg emphysema secondary to retroperitoneal perforation from diverticulitis have been reported.
Physical
Diverticulitis can present with a range of physical findings, mirroring the severity of the inflammation and the presence of complications.
- In simple diverticulitis, localized abdominal tenderness in the area of the affected diverticula and fever are common findings. Left lower quadrant tenderness is the most common physical finding, as most diverticula occur in the sigmoid colon. Right lower quadrant tenderness, mimicking acute appendicitis, can occur in right-sided diverticulitis.
- In complicated diverticulitis with abscess formation, a tender palpable mass may be felt on physical examination. In fact, 20% of cases present with a palpable mass on abdominal, pelvic, or rectal examination. Peritonitis due to free perforation results in generalized tenderness with rebound and guarding on abdominal examination. The abdomen may be distended and tympanic to percussion. Bowel sounds can be diminished or absent.
- Elderly patients and some patients taking corticosteroids may have unremarkable findings on physical examination even in the presence of severe diverticulitis. Such patients must be approached with a high index of suspicion to avoid a delay in establishing the correct diagnosis.
- If a fistula forms, the findings vary depending on the type of fistula. Colovesicular fistulas may present with urinary tract symptoms, such as suprapubic, flank, or costovertebral angle tenderness. Fecaluria can also be observed. Female patients with colovaginal fistulas may present with a purulent vaginal discharge.
Causes
See Pathophysiology.
More on Diverticulitis |
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| References |
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Further Reading
Keywords
diverticulum, diverticulosis, abdominal pain, chronic diverticular disease, diverticula, inflammation of diverticula, colon, abscess, peritonitis, colovesicular fistula, colovaginal fistula, constipation, colonic motility disorders
