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Diverticulosis is the presence of multiple diverticula in the colon, probably resulting from a lifelong low-fiber diet. Most diverticula are asymptomatic, but some become inflamed or bleed. Diagnosis is by colonoscopy or barium enema. Treatment varies depending on manifestation.
(See also the American College of Gastroenterology’s practice guidelines on the diagnosis and management of diverticular disease of the colon in adults .)
Diverticula occur anywhere in the large bowel—usually in the sigmoid but rarely below the peritoneal reflection of the rectum. They vary in diameter from 3 mm to > 3 cm. Patients with diverticula usually have several of them. Diverticulosis is uncommon in people < 40 but becomes common rapidly thereafter; essentially every 90-yr-old person has many diverticula. Giant diverticula, which are rare, range in diameter from 3 to 15 cm and may be single.
Diverticula are probably caused by increased intraluminal pressure leading to mucosal extrusion through the weakest points of the muscular layer of the bowel—areas adjacent to intramural blood vessels. Diverticula are more common among people who eat a low-fiber diet; however, the mechanism is not clear. One theory is that increased intraluminal pressure is required to move low-bulk stool through the colon. Another theory is that low-stool bulk causes a smaller diameter colon, which by Laplace’s law would have increased pressure.
The etiology of giant diverticula is unclear. One theory is that a valvelike abnormality exists at the base of the diverticulum, so bowel gas can enter but escapes less freely.
Most (70%) patients with diverticulosis are asymptomatic, 15 to 25% have symptomatic disease resulting from diverticulitis (inflammation of a diverticula), and 10 to 15% can have painless bleeding. The bleeding is probably caused by erosion of the adjacent vessel by local trauma from impacted feces in the diverticulum. Although most diverticula are distal, 75% of bleeding occurs from diverticula proximal to the splenic flexure. In 33% of patients (5% overall), bleeding is serious enough to require transfusion. Rarely, a patient may need surgery (colectomy or partial colectomy) for refractory bleeding.
Asymptomatic diverticula are usually found incidentally during colonoscopy, barium enema, or even CT of the abdomen. Diverticulosis is suspected when painless rectal bleeding develops, particularly in an elderly patient. Evaluation of rectal bleeding typically includes colonoscopy, which can be done electively after routine preparation unless there is significant ongoing bleeding. In such patients, a rapid preparation (5 to 10 L of polyethylene glycol solution delivered via NGT over 3 to 4 h) often allows adequate visualization. If colonoscopy cannot visualize the source and ongoing bleeding is sufficiently rapid (> 0.5 to 1 mL/min), angiography may localize the source. Some angiographers first do a radionuclide scan to focus the examination.
Treatment of diverticulosis aims at reducing segmental spasm. A high-fiber diet helps and may be supplemented by psyllium seed preparations or bran. Low-fiber diets are contraindicated. The intuitive injunction to avoid seeds or other dietary material that might become impacted in a diverticulum has no established medical basis. Antispasmodics (eg, belladonna) are not of benefit and may cause adverse effects. Surgery is unwarranted for uncomplicated disease. Giant diverticula, however, may require surgery.
Diverticular bleeding stops spontaneously in 75% of patients. Treatment is often given during diagnostic procedures. If angiography was done for diagnosis, ongoing bleeding can be controlled in 70 to 90% of patients by intra-arterial injection of vasopressin. In some cases, bleeding recurs within a few days and requires surgery. Angiographic embolization effectively stops bleeding but leads to bowel infarction in up to 20% of patients and is not recommended. Colonoscopy allows heat or laser coagulation of vessels or injection of epinephrine. If these measures fail to stop bleeding, segmental resection or subtotal colectomy is indicated.
Diverticulosis is the presence of multiple diverticula in the colon; diverticulitis is inflammation of a diverticulum.
Diverticulosis is rare in people < 40 and becomes increasingly common with age, particularly among people who eat a low-fiber diet.
Painless bleeding develops in 10 to 15% of patients, and painful inflammation (diverticulitis) develops in 15 to 25%.
Treat asymptomatic patients with a high-fiber diet.
Bleeding stops spontaneously in about 75% of patients; control the remainder during angiography with intra-arterial vasopressin or during colonoscopy with coagulation or epinephrine injection.
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