eMedicine Specialties > Emergency Medicine > Gastrointestinal

Diverticular Disease

Author: Bennett Goss, MD, MPH, Chief Resident Physician, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Coauthor(s): Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Contributor Information and Disclosures

Updated: Aug 17, 2009

Introduction

Background

Diverticular disease is a common disorder, yet it was not recognized as a pathologic entity until the mid-19th century. Diverticulitis and lower gastrointestinal (GI) bleeding secondary to diverticulosis are the main complications of clinical importance to emergency physicians.

Pathophysiology

Diverticular disease may involve any part of the GI tract. Typically, acquired, diverticular disease may be congenital, such as Meckel's diverticulum (although this is rare). Diverticula are herniations of the mucosa and submucosa or the entire wall thickness through the muscularis (as seen in congenital diverticula). The sigmoid is the most commonly affected segment (95-98%); however, diverticular disease may also involve the descending, ascending, and transverse colon as well as the jejunum, ileum, and duodenum.

Sigmoid diverticulitis in a 50-year-old man with ...

Sigmoid diverticulitis in a 50-year-old man with history of diverticulosis and left lower abdominal pain and tenderness. Media files 9 and 11-12 are sections from the same patient.

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Sigmoid diverticulitis in a 50-year-old man with ...

Sigmoid diverticulitis in a 50-year-old man with history of diverticulosis and left lower abdominal pain and tenderness. Media files 9 and 11-12 are sections from the same patient.



Phlegmon. Sigmoid diverticulitis in a 50-year-old...

Phlegmon. Sigmoid diverticulitis in a 50-year-old man with history of diverticulosis and left lower abdominal pain and tenderness. Images 11-12 are consecutive sections of the patient in Media files 9-10 showing a phlegmon.

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Phlegmon. Sigmoid diverticulitis in a 50-year-old...

Phlegmon. Sigmoid diverticulitis in a 50-year-old man with history of diverticulosis and left lower abdominal pain and tenderness. Images 11-12 are consecutive sections of the patient in Media files 9-10 showing a phlegmon.


 
Precise etiology of this disease is unknown. High intraluminal pressure and a weak colonic wall at the sites of nutrient vessel penetration into the muscularis may lead to herniation. The condition may also be caused by abnormal colonic motility, defective muscular structure, defects in collagen consistency (ie, increased cross-linking of collagen), and aging.
 
Diverticulitis is an abscess or peridiverticular inflammation initiated by the rupture of a microscopic mucosal abscess into the mesentery. The infection may progress, fistulize, obstruct, or spontaneously resolve. Acute diverticulitis results from the inspissation of fecal material in the neck of the diverticulum and resultant bacterial replication. Infection is generally contained by pericolonic fat or adjacent organs, at which point a local phlegmon develops. Macroperforation may cause peritonitis and may erode locally.
 
Lower GI bleeding from diverticulosis results from rupture of the small blood vessels that are stretched while coursing over the dome of the diverticula.

Frequency

United States

Diverticular disease affects primarily those in developed countries. Eighty years ago, the approximate prevalence of diverticular disease was between 5% and 10%. A large study performed in 2002 of 9,086 consecutive patients undergoing colonoscopies revealed a prevalence of 27%, in which prevalence increased with age.1  

International

Diverticular disease has been dubbed the "disease of Western civilization." In developed countries, the rate of diverticular disease is between 5% and 45%, depending on age and sex. In Africa and Asia, the prevalence is around 0.2% and is typically right sided.

Mortality/Morbidity

Morbidity and mortality associated with diverticular disease is primarily related to acute lower gastrointestinal bleeding, diverticulitis, and perforated diverticulum. Fifteen percent of persons with diverticular disease will develop acute GI bleeding. Of those, one third will develop massive GI bleeding. Risk of mortality with perforated diverticulum increases with age, comorbid conditions, and onset of perforation within the first year of diagnosis. Studies have reported mortality rates between 22% and 39% for free perforation and fecal peritonitis. Furthermore, multiple series have noted that perforation may be the first manifestation of complicated diverticulitis with a range in mortality of 50-70%.

Race

Diverticular disease primarily affects those in developed countries. However, the incidence of diverticular disease is increasing in Asian countries. In Asian and African countries, the prevalence of diverticular disease is approximately 0.2% and predominantly on the right side.

Sex

Gender variation occurs by age group. Diverticular disease is more prevalent in men than in women younger than 50 years. Between the ages of 50-70 years, a slight female predominance exists. In those older than 70 years, there is a female predominance.

Age

The prevalence of diverticular disease increases with age:

  • Less than 5% by age 40 years
  • Approximately 30% by age 60 years
  • 65% by age 85 years

Clinical

History

  • Clinical historical features of inflammatory disease include the following:
    • Abdominal pain - Occurs mostly in the left lower quadrant and tends to be steady, severe, and deep
    • History of fever suggestive of diverticulitis
    • Previous episodes of dull, colicky, and diffuse abdominal pain accompanied with flatulence, distention, and change in bowel habits (diverticulosis)
    • Altered bowel habits including diarrhea, increased constipation, and tenesmus (physician may note obstipation when treating a complicating bowel obstruction)
    • Nausea and vomiting
    • Dysuria, pyuria, and urinary frequency if bladder or ureter are irritated
    • History of pneumaturia or recurrent urinary tract infections (colovesicular fistulas)
    • Feculent vaginal discharge (fistulas with the uterus or vagina)
    • Severe and generalized abdominal pain (diffuse peritonitis)
    • Back or lower extremity pain (perforation)
  • Establish history of hemorrhagic disease, including the following:
    • Lower GI bleeding from diverticulosis occurs in the form of bright red-colored or wine-colored stools.
    • Onset of bleeding typically is sudden, painless, and accompanied by an urge to defecate.
    • Amount of bleeding typically is massive and tends to stop spontaneously.
    • Ascertain a previous history of gastric or duodenal ulcers, liver disease, or GI bleeding.
    • Discomfort and pain upon defecation indicate hemorrhoids or anal fissures.
    • History of weight loss and mucus in the stools indicates inflammatory bowel disease.
    • Establish list of medications used (nonsteroidal anti-inflammatory drugs [NSAIDs], steroids) and of alcohol abuse.
    • Establish bleeding tendencies.

Physical

  • Establish localized tenderness, rebound tenderness, and/or guarding. This is essential in the clinical management of diverticular disease. Their presence indicates diverticulitis.
  • When associated with GI bleeding, tenderness is not typical of diverticular etiology; it indicates other disease processes.
  • Assess vital signs to determine hemodynamic stability and profile of presentation.
  • Low-grade fever commonly is found in diverticulitis.
  • Rectal examination identifies tenderness, establishes the color of stools, and determines the presence and extent of GI bleeding. A mass may be seen in the cul-de-sac.
  • Diffuse abdominal tenderness, rebound, absent bowel sounds, and/or high-grade fever may be elicited. These indicate possible complications of perforation and/or peritonitis.
  • Pelvic and rectal examinations establish the correct diagnosis.
  • Palpate for any mass or fullness, particularly in the left iliac fossa.
  • Abdomen may be distended and tympanic.
  • Pain may be acute and located mainly in the left lower quadrant.

Causes

  • Low-fiber diet is the highest risk factor for diverticular disease. Common in industrialized nations, a low-fiber diet forms low-bulk stool that leads to increased segmentation of the colon during propulsion, causing increased intraluminal pressure and formation of diverticula.
  • High fat and beef diets also cause diverticular disease, probably for the same reasons as above.
  • Genetic causes exist. Asians have right-sided diverticula preponderance. In westerners, diverticula develop mostly on the left side.
  • Aging leads to change in collagen structure such as increased cross-linking and acid solubility.
  • Colonic motility disorders are a cause.
  • Corticosteroid therapy but not nonsteroidal anti-inflammatory therapy has recently been shown to increase the risk of diverticulitis.2
  • Colonic segmentation: Nonpropulsive contractions produce isolated segments or little chambers with high pressure within.
  • Defects in colonic wall strength can cause diverticular disease.

More on Diverticular Disease

Overview: Diverticular Disease
Differential Diagnoses & Workup: Diverticular Disease
Treatment & Medication: Diverticular Disease
Follow-up: Diverticular Disease
Multimedia: Diverticular Disease
References
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Further Reading

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Keywords

diverticular disease, diverticulitis, acute diverticulitis, diverticulosis, lower gastrointestinal bleeding, lower GI bleeding, Meckel iliac diverticulum, congenital diverticula, peridiverticular inflammation, tenesmus, recurrent urinary tract infections, colovesicular fistulas, pneumaturia, feculent vaginal discharge, low-fiber diet, high fat diets, beefdiets, colonic segmentation, defects in colonic wall strength

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Contributor Information and Disclosures

Author

Bennett Goss, MD, MPH, Chief Resident Physician, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Bennett Goss, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Gino A Farina, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Steven A Conrad, MD, PhD, Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center
Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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