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Diverticular disease

Last updated: July 6, 2020

Summary

Diverticular disease encompasses a set of colonic pathologies that result from abnormal outpouchings of the colonic mucosa (diverticula). It includes diverticulosis (noninflamed diverticula) and diverticulitis (inflamed diverticula). Colonic diverticula develop due to a combination of chronically elevated intraluminal pressures due to chronic constipation (e.g., due to low-fiber diets, lack of physical exercise) and age-related weakening of connective tissue. This causes the colonic mucosa to herniate through areas of weakness in the muscular layer. The sigmoid colon is most commonly involved. Incidence increases with age, and approx. 50% of individuals are affected by the 7th decade of life. Diverticulosis is typically asymptomatic but may manifest with lower gastrointestinal bleeding, altered bowel habits, and/or abdominal pain. Diverticulitis may remain localized (mild uncomplicated diverticulitis) or progress, resulting in complications such as abscess or perforation (complicated diverticulitis). Diverticulitis typically manifests with fever and left lower quadrant abdominal pain (as the sigmoid colon is most commonly involved). Colonoscopy is the diagnostic modality of choice for symptomatic diverticulosis but is contraindicated if acute diverticulitis is suspected. Abdominal CT scan with IV contrast is preferred in suspected acute diverticulitis. Uncomplicated diverticulitis usually responds to conservative management with bowel rest and analgesics; oral broad-spectrum antibiotics are reserved for patients at high risk of complications. In complicated diverticulitis, management consists of parenteral antibiotics, treatment of any complications, and, in some cases, emergency colonic resection. Once the acute phase has resolved, a colonoscopy is indicated to rule out malignancy. Elective colectomy is recommended for all patients with complicated diverticulitis that is managed conservatively. The procedure is not routinely indicated for uncomplicated diverticulitis.

Definition

  • Diverticula: blind pouches that protrude from the gastrointestinal wall and communicate with the lumen
    • True diverticulum; : a type of diverticulum that affects all layers of the intestinal wall.
    • False diverticulum or pseudodiverticulum: type of diverticulum that involves only the mucosa and submucosa and does not contain muscular layer or adventitia.
      • Most common type of gastrointestinal diverticula
      • Typically acquired
  • Diverticulosis: the presence of multiple colonic diverticula without evidence of infection [1]
  • Diverticulitis: inflammation or infection of colonic diverticula

Epidemiology

  • In the US, ∼ 50% of individuals > 60 years have diverticulosis [2]
  • More common in high-income countries due to the higher prevalence of a high-fat, low-fiber diet

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[4][5]

Pathophysiology

  • Diverticulosis: The formation of diverticula is considered multifactorial.
    • Increased intraluminal pressure; , e.g., due to chronic constipation
    • Weakness of the intestinal wall
      • Age-related loss of elasticity of the connective tissue
      • Physiological gaps in the intestinal wall, which occur where blood vessels penetrate, predispose to protrusion and herniation of intestinal mucosa and submucosa.
    • Localized particularly in the sigmoid colon
  • Diverticulitis
    • Most commonly: chronic inflammation and increased intraluminal pressure → erosion of diverticula wall → inflammation and bacterial translocation
    • Rarely: stool becomes lodged in diverticula → obstruction of intestinal lumen → inflammation

References:[6]

Clinical features

Diverticulosis

  • Usually asymptomatic
  • May manifest with abdominal discomfort; or pain, especially if associated with chronic constipation

Diverticulitis

In elderly or immunocompromised patients, clinical symptoms may only be mild.

References:[6][7]

Diagnostics

Diverticulosis

Asymptomatic diverticulosis [8]

  • Typically an incidental diagnosis
  • No workup required

Symptomatic diverticulosis [9][10][11][12][13]

  • Abdominal ultrasound
    • Indications: may be performed as part of the workup for nonspecific LLQ pain [11]
    • Findings: hypoechoic or anechoic outpouching from the colonic wall [13]

Colonoscopy is the diagnostic modality of choice for symptomatic diverticulosis.

Diverticulitis [14]

Suspect acute diverticulitis in adult patients presenting with LLQ pain, fever, and leukocytosis. The diagnosis is confirmed with imaging, preferably with IV contrast-enhanced CT scan. Once the acute phase has resolved, a colonoscopy should be performed to rule out malignancy. Colonoscopy is contraindicated in the acute phase because of the risk of perforation.

Laboratory studies [1][14][15]

Imaging [11][14][15][16][17][18]

  • MRI abdomen and pelvis (without and with IV contrast)
    • Indications: suspected diverticulitis in patients with contraindications to CT [11]
    • Findings: similar to those on CT scan
  • Ultrasound abdomen
    • Indications: an alternative to MRI in patients with contraindications to CT
    • Supportive findings: diverticula with surrounding inflammation (hyperechoic), abscess formation (detectable fluid), bowel wall thickening

Avoid colonoscopy during the acute phase of diverticulitis because of the risk of perforation!

Classification of diverticulitis

  • To choose the best treatment approach and determine the prognosis, identifying the stage of acute diverticulitis is recommended. [15]
  • The modified Hinchey classification is based on CT findings and is the most commonly used classification.
Modified Hinchey classification of diverticulitis [17][18][20]

Stage

CT findings Interpretation
Inflammation 0
Ia
Abscess Ib
  • Stage Ia findings
  • PLUS pericolic abscess
II
  • Stage Ia findings
  • PLUS an abscess distant to the primary infection
Perforation III
IV

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

Diverticulosis

  • Asymptomatic diverticulosis
    • No treatment can reverse the growth of existing diverticula.
    • The goal is the prevention of progression (see “Prevention of recurrence and disease progression” below).
  • Symptomatic diverticulosis: see “Treatment” in GI bleeding

Diverticulitis [13][18][21]

Approach

Acute management

Uncomplicated diverticulitis [15][18][21]

Complicated diverticulitis [17][18][19][21] [22]

Subsequent management

Elective colectomy [14][15][18][19]

Prevention of recurrence and disease progression [17][19]

  • High-fiber diet [19][25]
  • Fluid hydration
  • Weight reduction
  • Vigorous physical activity
  • Cessation of smoking
  • Avoid nonaspirin NSAID use, if possible.

Acute management checklist

Uncomplicated diverticulitis [14]

  • Clear liquid diet
  • Supportive care
  • Consider broad-spectrum oral antibiotics in patients at high risk for complications (not routinely indicated). [23]
  • Outpatient treatment with follow-up in 2–3 days or earlier if symptoms worsen
  • Refer for colonoscopy after the resolution of symptoms

Complicated diverticulitis [18][24]

Complications

References:[7][26][27]

We list the most important complications. The selection is not exhaustive.

References

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  3. Tochigi T, Kosugi C, Shuto K, Mori M, Hirano A, Koda K. Management of complicated diverticulitis of the colon.. Annals of gastroenterological surgery. 2018; 2 (1): p.22-27. doi: 10.1002/ags3.12035 . | Open in Read by QxMD
  4. Siewert B, Tye G, Kruskal J, Sosna J, Opelka F. Impact of CT-Guided Drainage in the Treatment of Diverticular Abscesses: Size Matters. American Journal of Roentgenology. 2006; 186 (3): p.680-686. doi: 10.2214/ajr.04.1708 . | Open in Read by QxMD
  5. Strate LL, Morris AM. Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology. 2019; 156 (5): p.1282-1298.e1. doi: 10.1053/j.gastro.2018.12.033 . | Open in Read by QxMD
  6. Adam V Weizman and Geoffrey C Nguyen. Diverticular disease: Epidemiology and management. Canadian Journal of Gastroenterology and Hepatology. 2011 .
  7. Goldblum JR, Lamps LW, McKenney J, Myers JL. Rosai and Ackerman's Surgical Pathology - 2 Volume Set. Mosby ; 2017
  8. Weizman AV, Nguyen GC. Diverticular disease: Epidemiology and management. undefined. 2011 .
  9. Reichert MC, Lammert F. The genetic epidemiology of diverticulosis and diverticular disease: Emerging evidence. undefined. 2015 .
  10. Pemberton JH. Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/colonic-diverticulosis-and-diverticular-disease-epidemiology-risk-factors-and-pathogenesis.Last updated: June 16, 2016. Accessed: December 5, 2016.
  11. Pemberton JH. Clinical manifestations and diagnosis of acute diverticulitis in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-acute-diverticulitis-in-adults.Last updated: December 15, 2015. Accessed: December 12, 2016.
  12. Floch MH. Netter's Gastroenterology. Elsevier Health Sciences ; 2019
  13. Snyder MJ. Imaging of Colonic Diverticular Disease. Clinics in Colon and Rectal Surgery. 2004; 17 (3): p.155-162. doi: 10.1055/s-2004-832696 . | Open in Read by QxMD
  14. ACR - Practice parameter for the performance of fluoroscopic contrast enema examination in adults.
  15. American College of Radiology (ACR) Appropriateness Criteria® - Left Lower Quadrant Pain. https://acsearch.acr.org/docs/69356/Narrative/. Updated: January 1, 2018. Accessed: August 28, 2019.
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  17. Salzman H, Lillie D. Diverticular disease: diagnosis and treatment.. Am Fam Physician. 2005; 72 (7): p.1229-34.
  18. Feingold D, Steele SR, Lee S, et al. Practice Parameters for the Treatment of Sigmoid Diverticulitis. Diseases of the Colon & Rectum. 2014; 57 (3): p.284-294. doi: 10.1097/dcr.0000000000000075 . | Open in Read by QxMD
  19. DeStigter K, Keating D. Imaging Update: Acute Colonic Diverticulitis. Clinics in Colon and Rectal Surgery. 2009; 22 (03): p.147-155. doi: 10.1055/s-0029-1236158 . | Open in Read by QxMD
  20. Andeweg CS, Mulder IM, Felt-Bersma RJF, et al. Guidelines of Diagnostics and Treatment of Acute Left-Sided Colonic Diverticulitis. Dig Surg. 2013; 30 (4-6): p.278-292. doi: 10.1159/000354035 . | Open in Read by QxMD
  21. Stollman N, Smalley W, Hirano I, et al. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology. 2015; 149 (7): p.1944-1949. doi: 10.1053/j.gastro.2015.10.003 . | Open in Read by QxMD
  22. Onur MR, Akpinar E, Karaosmanoglu AD, Isayev C, Karcaaltincaba M. Diverticulitis: a comprehensive review with usual and unusual complications. Insights into Imaging. 2016; 8 (1): p.19-27. doi: 10.1007/s13244-016-0532-3 . | Open in Read by QxMD
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  27. Pemberton JH. Acute diverticulitis complicated by fistula formation. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/acute-diverticulitis-complicated-by-fistula-formation.Last updated: September 23, 2015. Accessed: December 13, 2016.
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