DIVERTICULUM DISEASE

INTRODUCTION
Diverticula are saclike mucosal outpouchings that protrude from a tubular structure. True
diverticula contain all layers of the parent structure. False or pseudodiverticula are mucosal
projections through the muscular layer. Esophageal (see Esophageal and Swallowing Disorders:
Esophageal Diverticula) and Meckel's diverticula are true diverticula. Colonic diverticula are
pseudodiverticula; they cause symptoms by trapping feces and becoming inflamed or infected,
bleeding, or rupturing.

DIVERTICULAR DISEASE OF THE SMALL BOWEL

Diverticula rarely involve the stomach but occur in the duodenum in up to 25% of people. Most
duodenal diverticula are solitary and occur in the second portion of the duodenum near the ampulla
of Vater (periampullary). Jejunal diverticula occur in about 0.26% of patients and are more
common among patients with disorders of intestinal motility. Meckel's diverticulum occurs in the
distal ileum.

Duodenal and jejunal diverticula are asymptomatic in > 90% of cases and are usually detected
incidentally during radiologic or endoscopic investigation of the upper GI tract for an unrelated
disease. Rarely, small-bowel diverticula bleed or become inflamed, causing pain and nausea. Some
even perforate. For poorly understood reasons, patients with periampullary diverticula are at
increased risk of gallstones and pancreatitis. Treatment is surgical resection; however, the clinician
should be cautious of recommending surgery for patients with a diverticulum and vague GI
symptoms (eg, dyspepsia).

DIVERTICULITIS
Diverticulitis is inflammation of a diverticulum, which can result in phlegmon of the bowel wall,
peritonitis, perforation, fistula, or abscess. The primary symptom is abdominal pain. Diagnosis is by
CT scan. Treatment is with antibiotics (ciprofloxacin, or a 3rd-generation cephalosporin plus
metronidazole) and occasionally surgery.

Diverticulitis

Diverticulitis occurs when a micro or macro perforation develops in a diverticulum, releasing

intestinal bacteria. The resultant inflammation remains localized in about 75% of patients. The
remaining 25% may develop abscess, free intraperitoneal perforation, bowel obstruction, or
fistulas. The most common fistulas involve the bladder but may also involve the small bowel,
uterus, vagina, abdominal wall, or even the thigh.

Dipti’s notes 1
Diverticulitis is most serious in elderly patients, especially those taking prednisone SOME TRADE
NAMES DELTASONEClick for Drug Monograph or other drugs that increase the risk of infection.
Nearly all serious diverticulitis occurs in the sigmoid.

Symptoms and Signs

Diverticulitis usually manifests with pain or tenderness in the left lower quadrant of the abdomen
and fever. Peritoneal signs (eg, rebound or guarding) may be present, particularly with abscess or
free perforation. Fistulas may manifest as pneumaturia, feculent vaginal discharge, or a cutaneous
or myofascial infection of the abdominal wall, perineum, or upper leg. Patients with bowel
obstruction have nausea, vomiting, and abdominal distention. Bleeding is uncommon.

Diagnosis
 Abdominal CT
 Colonoscopy after resolution

Clinical suspicion is high in patients with known diverticulosis. However, because other disorders
(eg, appendicitis, colon or ovarian cancer) may cause similar symptoms, testing is required.
Abdominal CT scan with oral and IV contrast is preferred, although findings in about 10% of
patients cannot be distinguished from colon cancer. Colonoscopy, after resolution of the acute
infection, is necessary for definitive diagnosis.

Treatment
 Varies with severity
 Liquid diet, oral antibiotics for mild disease
 IV antibiotics, npo for more severe disease
 CT-guided percutaneous drainage of abscess
 Sometimes surgery

A patient who is not very ill is treated at home with rest, a liquid diet, and oral antibiotics (eg,
ciprofloxacin SOME TRADE NAMES CILOXANCIPROClick for Drug Monograph 500 mg bid
amoxicillin/clavulanate SOME TRADE NAMES AUGMENTINClick for Drug Monograph 500 mg tid plus
metronidazole SOME TRADE NAMES FLAGYLClick for Drug Monograph 500 mg qid). Symptoms
usually subside rapidly. The patient gradually advances to a soft low-fiber diet and a daily psyllium
seed preparation. The colon should be evaluated after 2 to 4 wk with a colonoscopy or barium
enema. After 1 mo, a high-fiber diet is resumed.

Patients with more severe symptoms (eg, pain, fever, marked leukocytosis) should be hospitalized,
as should patients taking prednisone SOME TRADE NAMES
DELTASONEClick for Drug Monograph (who are at higher risk of perforation and general
peritonitis). Treatment is bed rest, npo, IV fluids, and IV antibiotics (eg, ceftazidime SOME TRADE
NAMES FORTAZTAZICEFClick for Drug Monograph 1 g IV q 8 h plus metronidazole SOME TRADE
NAMES
FLAGYLClick for Drug Monograph 500 mg IV q 6 to 8 h).

Dipti’s notes 2
About 80% of patients can be treated successfully without surgery. An abscess may respond to
percutaneous drainage (CT guided). If response is satisfactory, the patient remains hospitalized
until symptoms are relieved and a soft diet is resumed. A colonoscopy or barium enema is done ≥
2 wk after symptoms have resolved.

Surgery: Surgery is required immediately for patients with free perforation or general peritonitis
and for patients with severe symptoms that do not respond to nonsurgical treatment within 48 h.
Increasing pain, tenderness, and fever are other signs that surgery is needed. Surgery should also
be considered in patients with any of the following: ≥ 2 previous attacks of mild diverticulitis (or
one attack in a patient < 50); a persistent tender mass; clinical, endoscopic, or x-ray signs
suggestive of cancer; and dysuria associated with diverticulitis in men (or in women who have had
a hysterectomy), because this symptom may presage perforation into the bladder.

The involved section of the colon is resected. The ends can be reanastomosed immediately in
healthy patients without perforation, abscess, or significant inflammation. Other patients have a
temporary colostomy with anastomosis carried out in a subsequent operation after inflammation
resolves and the patient's general condition improves.

DIVERTICULOSIS
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 .)

Diverticulosis

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.

Pathophysiology
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-

Dipti’s notes 3
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.

Symptoms and Signs

Most (70%) diverticula are asymptomatic, 15 to 25% become painfully inflamed (diverticulitis),
and 10 to 15% bleed painlessly. 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.

Diagnosis
 Usually colonoscopy

Asymptomatic diverticula are usually found incidentally during barium enema or colonoscopy.
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 perform a radionuclide scan to focus the examination.

Treatment
 High-fiber diet
 Sometimes angiographic or endoscopic treatment of bleeding

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, require surgery.

Diverticular bleeding stops spontaneously in 75% of patients. Treatment is often given during
diagnostic procedures. If angiography was performed for diagnosis, ongoing bleeding can be
controlled in 70 to 90% of patients by intra-arterial injection of vasopressin SOME TRADE NAMES
PITRESSINClick for Drug Monograph . 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 SOME TRADE NAMES ADRENALINPRIMATENE MISTClick for Drug
Monograph . If these measures fail to stop bleeding, segmental resection or subtotal colectomy is
indicated.

Dipti’s notes 4
 MECKEL’S DIVERTICULUM
Meckel's diverticulum is a congenital sacculation of the distal ileum occurring in 2 to 3% of people.
It is usually located within 100 cm of the ileocecal valve and often contains heterotopic gastric
tissue, pancreatic tissue, or both. Symptoms are uncommon but include bleeding, bowel
obstruction, and inflammation (diverticulitis). Diagnosis is difficult and often involves radionuclide
scanning and barium studies. Treatment is surgical resection.

Pathophysiology
In early fetal life, the vitelline duct running from the terminal ileum to the umbilicus and yolk sac is
normally obliterated by the 7th wk. If the portion connecting to the ileum fails to atrophy, a
Meckel's diverticulum results. This congenital diverticulum arises from the antimesenteric margin of
the intestine and contains all layers of the normal bowel. About 50% of diverticula also contain
heterotopic tissue of the stomach (and thus contain parietal cells that secrete HCl), pancreas, or
both.

Only about 2% of people with Meckel's diverticulum develop complications. Although diverticula are
equally common among males and females, males are 2 to 3 times more likely to have
complications. Complications include the following:

 Bleeding
 Obstruction
 Diverticulitis
 Tumors

Bleeding is more common among young children (< 5 yr) and occurs when acid secreted from
ectopic gastric mucosa in the diverticulum ulcerates the adjacent ileum. Obstruction can occur at
any age but is more common among older children and adults. In children, obstruction is most
likely caused by intussusception of the diverticulum. Obstruction may also result from adhesions,
volvulus, retained foreign bodies, tumors, or incarceration in a hernia (Littre's hernia). Acute
Meckel's diverticulitis can occur at any age, but its incidence peaks in older children. Tumors,
including carcinoids, are rare and occur mainly in adults.

Symptoms and Signs

In all ages, intestinal obstruction is manifested by cramping abdominal pain, nausea, and vomiting.
Acute Meckel's diverticulitis is characterized by abdominal pain and tenderness typically localized
below or to the left of the umbilicus; it is often accompanied by vomiting and is similar to
appendicitis except for location of pain.

Children may present with repeated episodes of painless, bright red rectal bleeding, which is
usually not severe enough to cause shock. Adults may also bleed, typically resulting in melena
rather than frank blood.

Diagnosis
 Based on symptoms
Dipti’s notes 5
 Radionuclide scan for bleeding
 CT scan for pain

Diagnosis is difficult, and tests are chosen based on presenting symptoms. If rectal bleeding is
99m
suspected to originate from a Meckel's diverticulum, a Tc pertechnetate scan may identify
ectopic gastric mucosa and hence the diverticulum. Patients presenting with abdominal pain and
focal tenderness should have a CT scan with oral contrast. If vomiting and signs of obstruction are
predominant, flat and upright x-rays of the abdomen are done. Sometimes diagnosis is made only
during surgical exploration for presumed appendicitis; whenever a normal appendix is found,
Meckel's diverticulum should be suspected.

Treatment
 Surgery

Patients with intestinal obstruction from Meckel's diverticulum require early surgery. For detailed
treatment of intestinal obstruction, see Acute Abdomen and Surgical Gastroenterology: Treatment.

A bleeding diverticulum with an indurated area in the adjacent ileum requires resection of this
section of the bowel and the diverticulum. A bleeding diverticulum without ileal induration requires
only resection of the diverticulum.

Meckel's diverticulitis also requires resection. Small, asymptomatic diverticula encountered

incidentally at laparotomy need not be removed.

Dipti’s notes 6