Diverticulosis and Diverticulitis
Although relatively few individuals are familiar with diverticular disease, the odds are overwhelmingly indicative that just about everyone will develop the condition – mild or severe – during their lifetime.
By Mike Haskew
Statistics compiled by the National Digestive Disease Clearinghouse suggest that diverticular disease becomes more prevalent with age, occurring in roughly half of the U.S. population between the ages of 60 and 80, while nearly everyone over the age of 80 has developed the condition to some degree. Younger people are somewhat susceptible to diverticular disease; it appears in some individuals during their 30s. Diverticular disease apparently occurs most often in Western society, while it is somewhat rare among the populations of rural areas in Africa, China and on the Indian subcontinent. Such a pattern is a strong indicator that a fiber-rich diet may delay its onset.
Two conditions, diverticulosis and diverticulitis, are most commonly associated with the general term “diverticular disease,” which is basically defined as the presence of pockets or bulges (diverticula, singular term is diverticulum) extending from the colon – also known as the large intestine.
Diverticula can develop as a result of the lifelong wear and tear that is placed on the intestine. As food moves through the digestive tract, it travels from the stomach through the small intestine, into the large intestine, which functions primarily to form stool, into the rectum and out of the body. The sigmoid colon, which is shaped like a large “S,” specializes in dehydrating liquid stool under high pressure. It contracts vigorously and forms solid stool, which then moves into the rectum. Due to the high pressure and strong contractions which take place in the sigmoid colon, pockets or sacs may form in natural weak spots. While diverticula may become present in other areas of the digestive tract, the majority of them are located in the sigmoid colon.
According to Dr. J. Scott Manton, a gastroenterologist with Chattanooga’s Digestive Health Associates, diverticular disease may refer to diverticulosis, diverticulitis or diverticular bleeding.
Dr. Manton explains: Diverticulosis is the presence of diverticula, which are sac-like protrusions from the colon wall or “pouches.” Diverticulitis is inflammation of the diverticulum, which is most commonly associated with pain in the lower left portion of the abdomen. Other symptoms of diverticulitis may include fever, nausea, vomiting, constipation or diarrhea. Diverticular bleeding occurs from a blood vessel within the diverticulum. The bleeding is usually painless and abrupt, and the blood passed is usually bright red or dark red and may have clots. Generally, the volume is moderate to large because this is an arterial bleed.
While the incidence of diverticulosis increases substantially with age, those who develop the condition are still generally unlikely to progress to the more serious diverticulitis.
“Diverticulosis is extremely common,” says Dr. Richard Sadowitz, a gastroenterologist with Chattanooga Gastroenterology, “and about 80 percent of the people I do a colonoscopy on would have it. Of those, only about 20 percent ever get diverticulitis, and I would say that 90 percent of the patients with diverticulitis usually have a good outcome.”
Although diverticular disease is extremely treatable, patients can develop infections and other complications. Immediate medical attention is required with the onset of symptoms. Most cases of diverticulitis are resolved with antibiotic treatment and do not require surgery. The presence of diverticular disease is determined by a CT scan, colonoscopy or a barium enema.
Diverticulosis can progress to diverticulitis when the diverticula trap small particles of food or stool and become inflamed or infected. While only 15 to 25 percent of patients with diverticulosis will progress to diverticulitis, the most common complications include an abscess, an area where pus collects due to infection; a fistula, an abnormal connection between a diverticulum and another surrounding structure, such as the urinary bladder or bowel; a perforation, a condition in which a hole develops in the diverticulum; or an obstruction.
Dr. Sadowitz remarks, “With diverticulitis, many times the primary care doctor can start antibiotics and do a white blood cell count to detect the presence of infection. Some patients would not need to see me; however, when you have diverticulitis, a colonoscopy is warranted many times to make sure nothing else is going on in the colon that could have caused the symptoms, such as a tumor or a polyp.
“The first thing to do is make sure what is causing the abdominal pain, cramping, fever or other symptoms,” continues Dr. Sadowitz. “A high white count could indicate an infection, which can be cleared up with antibiotics. Sometimes, we may do a CT scan, depending on how severe the pain is and how high the white count has risen. This helps to determine how big the affected area is and whether there is an abscess. The presence of an abscess would require that the pocket be drained, and the patient would probably be in the hospital to have the drain placed and to be on a longer course of IV (intravenous) antibiotics.”
According to Dr. Sadowitz, the “controlled” rupture of diverticula can cause an abscess to form, perforating the wall of the intestine. Should an abscess go untreated and subsequently rupture, surgery would probably be needed and the patient would run the risk of developing peritonitis, the inflammation of the lining of the abdomen.
The prevention of diverticular disease and the lessening of its severity are commonly linked to an individual’s lifestyle and dietary habits. For most, plenty of exercise, a high-fiber diet, and drinking lots of water – all of which help to keep the colon active and regular – are basic measures that can be taken for good health. Roughage, bran and fiber – particularly wheat bran – retain large amounts of water, thereby producing a bulkier stool and allowing the sigmoid colon to contract less vigorously. In turn, lower pressure is generated in the colon and the likelihood of developing diverticula is diminished.
Health care professionals recommend that individuals consume between 25 and 40 grams of fiber per day. An increase in fiber should be gradual in order to avoid discomfort, such as gassiness or bloating. Over a period of several weeks, the concentration of dietary fiber should be increased up to five grams per week, which is approximately the amount found in a single cup of cooked carrots. Vegetables, particularly leafy greens such as kale, collards and turnip greens, are not only a good source of fiber, they also retain large amounts of water.
“Interestingly, the risk factors for diverticular disease mirror those for colon cancer, except there is no known genetic link for diverticular disease,” says Dr. Munford R. Yates, a gastroenterologist with Galen Medical Group. “A high-fiber diet is very important for the prevention of the disease and its complications. The old dictum of telling patients not to eat seeds, popcorn, etc., is controversial. New studies refute this recommendation and should be reconsidered. Losing weight and performing physical activity must also be recommended.”
The incidence of diverticular disease is not linked to gender, with the condition occurring in roughly equal numbers of men and women. However, males under 40 years of age who begin with diverticulosis do have a higher rate of progression to diverticulitis than other age and gender groups. Those who are overweight and inactive are believed to be at greater risk for the development of the disease, as well.
“An obese, sedentary, elderly person on a low-fiber diet who lives in the Western Hemisphere is a prototypic patient with diverticular disease,” notes Dr. Yates. “A diet rich in fiber – like grains, fruits and vegetables – will prevent diverticular disease and may decrease its complications. Anti-spasm medications will decrease symptoms related to pain and to uncomplicated diverticular disease. Antibiotics will treat infectious complications of diverticulitis, leaving surgery with colonic resection as the last option. With respect to diverticular bleeding, endoscopic intervention is the first line of treatment, with surgical resection as the ultimate treatment.”
For those managing diverticular disease, attention to details and awareness of worsening symptoms are the key defenses against complications. For those who have been diagnosed with diverticular disease, if they begin to exhibit symptoms of diverticulitis, they should seek medical treatment immediately.
“Some people may need to add fiber to their diet,” suggests Dr. Sadowitz, “with supplements like FiberCon, Metamucil or Citrucil. These are not water-soluble, so they are thick and tough to drink. Some individuals do better with water-soluble fiber supplements, such as Fibersure, Benefiber and UniFiber. They usually are easier to take and can be put into food, rather than just drinking them.”
Although it is likely that a person living into their 60s will develop diverticular disease to some degree, most will never know they have the condition. Complications are preventable, and the best news of all is that effective treatment is available for those willing to address the disease proactively.