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Diverticular Disease

Definition
Diverticulosis is the presence of out-pouchings of gastrointestinal mucosa known as diverticulae. If
they become infected this is known as diverticulitis. It is most common in the colon with the
majority of disease concentrated in the sigmoid (95%). An acquired colonic diverticulum is a false
diverticulum because it does not contain all of the layers of the wall (muscularis not included).

Incidence
Diverticulosis is present in 1/3 of adults at the age of 45 and 2/3 adults by the age of 85.

Age
Increases with age. Rare under the age of 40 years.

Sex
Slightly more common in females, 3:2.

Geography
Primarily the Western world. In Asians and Africans the occurrence of diverticulosis is only about
0.2% of the population but in immigrants the frequency seems to match that of the Western World
by 10 years.

Aetiology
Diverticulae can be classified as congenital or acquired, true or fasle and pulsion or traction. Most
congenital diverticulae are true (containing all layers of the wall of the viscus, for example Meckel's
diverticulm) and most cases of acquired cases are false, for example colonic diverticulae.
The exact aetiology of colonic diverticular disease is poorly understood. It is thought that high
intraluminal pressures generated in those with motility problems or constipation is a significant
factor. Diverticulae occur in a natural weakening in the bowel wall where the nutrient vessels pierce
the muscularis near the taeniae coli and the gastroepiploic appendages. These defects also probably
become weaker with age or connective tissue disorders.
Diverticulitis occurs in only about 10-20% of patients with diverticulosis. It probably ensues after
the presence of a faecolith causing stasis with bacterial overgrowth as well as causing mucosal
erosion and reducing perfusion because of the direct pressure effect. Thus inflammation and
infection follow producing a diverticular phlegmon.
At this stage the process may be arrested with antibiotics but, especially if left untreated, several
complications may occur.
Perforation of the affected diverticulum can occur which may cause generalised peritonitis. More
commonly, however, a perforation is walled off by the greater omentum or pericolic fat causing a
diverticular abscess or sinus which may in turn lead to fistula formation. In chronic disease
fibrosis may also occur leading to a benign stricture.
Haemorrhage can also occur from the nutrient vessel which is always in close proximity to
diverticulae.

Predisposing factors
For diverticulosis: Age, high fat/meat and low fibre diet, decreased exercise, connective tissue
disorders
For diverticulitis: constipation & steroids

Macroscopic & Microscopic appearances


Diverticulae can be diagnosed by endoscopy where the small, sometimes pinpoint hole can be seen
leading into a diverticulum. However, they can sometimes be missed so the investigation of choice
is normally barium enema which will nicely demonstrate multiple out-pouchings.
The inflamed colonic mucosa present in diverticulitis is not seen so often because of the danger of
perforation with the endoscope when inflammation is present. CT is performed in this instance and
may demonstrate diverticulae with oedema of the bowel wall, stranding (indicating oedema) in the
pericolic fat and even abscesses.
If there is an abscess or perforation the affected segment will be resected and we will see grossly
oedematous colon wall often with extensive diverticulae. Generalised faeculent peritonitis or
localised collections are normally present.
Microscopically, diverticulae extend through the muscle layer and so their wall consists simply of
mucosa, submucosa and serosa. A histological picture of acute (often with an element of chronic)
inflammation would be present in diverticulitis. There is often microscopic perforation even is it is
not seen macroscopically.
The Hinchley diverticulitis grading system describes the four distinct pathological findings.

Clinical features
The most common presentation of acute diverticulitis is with fever and LIF pain. An acute change
in bowel habit ranging from diarrhoea to constipation is also frequent, with diarrhoea being the
norm. Mild bleeding is present in about 25% of patients and dysuria indicates bladder irritation.
On examination, the patient is usually in considerable discomfort, lying still with a tachycardia and
may demonstrate other signs of sepsis. Most patients exhibit LIF tenderness and possibly localised
or less commonly generalised peritonism. A mass is sometimes palpated. Urine dip may show
leukocytes but should not show nitrites. FBC will demonstrate a leukocytosis and raised
inflammatory markers.

Prognosis
As mentioned earlier, the finding of diverticular disease in the majority of people is incidental and
need no further treatment except dietary advice.
Acute diverticulitis is most often successfully treated with antibiotics (eg cefuroxime and
metronidazole) although it recurs within 2 years in 5%. However, 20% of patients eventually
require surgery. If this is required in the acute scenario there is a mortality of almost 8%.
If an abscess or perforation of sigmoid diverticular disease necessitates operation, a Hartmann's
procedure is normally performed which may sometimes be reversed at a later date. If a patient is
complaining of recurrent attacks of sigmoid diverticulitis or has a fistula, an anterior resection
(with the anastomosis sometimes protected with a loop ileostomy) is planned electively.