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Colonic Diverticulosis

Diverticular Diseases of the Colon

Colonic diverticulosis, defined as the presence of pouches or herniations formed from the colon's mucosa and submucosa, is a rather common condition in the elderly population. A low-fiber diet is assumed to be the main risk factor. The majority of patients are asymptomatic, whereas inflammatory changes and infections of diverticula can lead to symptoms such as fever, abdominal pain, bloating, and even lower gastrointestinal bleeding. Computed tomography is the main diagnostic procedure used for detecting colonic diverticulosis.


Presentation

Diverticulosis is a term denoting the presence of several sac-like structures that stem from the mucosa and submucosa of the intestinal wall, and it's almost exclusive location in the large intestine explains why the term "colonic diverticulosis" is used [1] [2] [3] [4] [5]. In recent years, it has become evident that colonic diverticulosis is quite commonly found in the senile population primarily living in the Western world, with the single most important risk factor being a low-fiber diet [2] [3] [6]. Furthermore, obesity and certain drug groups (opioids, corticosteroids, and non-steroidal anti-inflammatory drugs, or NSAIDs) have also been associated with colonic diverticulosis [2]. The clinical presentation is asymptomatic in 70-80% of patients, which is supported by the fact that they are one of the most frequent incidental findings on colonoscopy [2] [4] [5]. Symptoms may appear in the presence of an infection (termed diverticulitis), while diverticular disease refers to the development of typical lower gastrointestinal tract symptoms - abdominal pain (often on the left side), cramping, fever, and bloating [3] [4] [5] [6]. Altered bowel habits (more commonly constipation than diarrhea) and a sense of fullness in the lower left quadrant are also reported, whereas painless rectal bleeding (abrupt and sometimes voluminous) is a highly indicative sign of an ongoing disease in the lower gastrointestinal tract [5] [6]. Both acute and chronic course of illness has been reported [5].

Abdominal Obesity
  • RESULTS: In multivariate analysis, diverticulosis was significantly associated with VAT area and SAT area for both categorical data and trend (P for trend CONCLUSIONS: Abdominal obesity measured by CT, not BMI, is associated with colonic diverticulosis[ncbi.nlm.nih.gov]
Chest Discomfort
  • The items, which showed difference, were hard stool, urgency, flatus, chest discomfort and frequent urination. In conclusion, old age, diabetes and the presence of colon polyp were associated with proximal diverticulosis.[ncbi.nlm.nih.gov]
Hematochezia
  • Diverticular bleeding manifests as painless hematochezia. Because the bleeding vessel is an arteriole, the amount of blood loss is usually moderate to severe.[merckmanuals.com]
  • Images in Clinical Medicine George Triadafilopoulos, M.D. 4 Citing Articles Figure 1 A 42-year-old man with a history of mild, intermittent pain on the lower left side of the abdomen presented with an episode of painless hematochezia.[nejm.org]
  • ., intestinal strictures, fistulas ) References: [4] [6] [7] Complications Diverticular bleeding Frequency: occurs in around 5% of cases of patients with diverticulosis Caused by erosions around the edge of diverticula Clinical findings Painless hematochezia[amboss.com]
Suprapubic Pain
  • . - Marked by suprapubic pain, shifting to left iliac fossa. - Fever, nausea and vomiting. - ‘left-sided appendicitis’. - Local signs of peritonitis, colicky abdominal pain, raised WCC. - Change in bowel habit eg.constipation. • Perforated diverticulitis[slideshare.net]

Workup

The diagnosis of colonic diverticulosis must be considered in old-age patients who present with lower gastrointestinal tract related symptoms. A properly obtained history is the first step, during which assessment of risk factors, such as dietary intake of fiber and use of various drugs, as well as the course and progression of symptoms, should be noted. Physical examination can reveal tenderness in the lower left quadrant in symptomatic patients, while palpation of the sigmoid colon in this area is also seen in colonic diverticulosis [5]. To solidify the diagnosis, imaging studies need to be performed. Barium enema was previously considered as the gold standard in the evaluation of colonic diverticulosis, but in the presence of an intestinal perforation, the contrast material may reach extraintestinal tissue and cause complications [5]. For this reason, computed tomography (CT) has emerged as the optimal procedure [1] [3] [5]. The presence of air-filled pouches arising from the colonic wall, primarily located in the sigmoid colon, are hallmarks of colonic diverticulosis [1]. In addition, ultrasonography has been described as a beneficial method in certain studies, describing diverticula as hypoechoic or anechoic structures protruding from the colonic wall that shows signs of hypertrophy [5]. Finally, colonoscopy should be employed as a definite method if inconclusive findings are obtained from CT or ultrasonography, although CT colonography is becoming a suitable replacement, being less invasive but equally effective than colonoscopy [5].

Treatment

  • Diverticulitis may progress into abscess formation, if treatment is delayed, the diverticuli may perforate and cause life threatening peritonitis. Treatment As diverticuli are closed to blood vessels, inflammation may cause bleeding.[colorectal.com.hk]
  • Asymptomatic diverticulosis requires no treatment. When symptoms develop, treatment varies depending on clinical manifestations.[merckmanuals.com]
  • Recent advances in pharmacoagiography and and embolization promise successful treatment with lower morbidity than surgical resection.[ncbi.nlm.nih.gov]
  • A RCT, by Trespi and Coll [ 33 ] compared 8 weeks of treatment with oral mesalazine (400 mg twice daily) versus no treatment.[omicsonline.org]
  • Definitive treatment included resection of the fistula and the diseased segment of the intestine. Both patients are well on follow-up.[ncbi.nlm.nih.gov]

Prognosis

  • Treatment and prognosis The majority of patients remain asymptomatic throughout life and no treatment is required. A high fiber diet may reduce the incidence of diverticula and rate of complications 7 .[radiopaedia.org]
  • Course & Prognosis • 10-20% of patients experience complications, mainly diverticulitis and lower GI bleeding. • Conservative management of diverticular disease is preferred. • Surgery reserved for major complications. • In UK, surgery usually for cases[slideshare.net]
  • Pharyngeal diverticulae can cause: bronchitis, bronchiectasis lung abscess diverticulitis fistulae malignancy Small bowel disease can cause: bleeding impaction diverticulitis perforation neoplasm biliary tree obstruction Worse prognosis is seen in females[sharinginhealth.com]

Etiology

  • A special care and follow-up may be needed in RTRs with autosomal dominant polycystic kidney disease etiology, smoking history, and coronary artery disease due to higher risk of diverticulosis and subsequent potential diverticulitis.[ncbi.nlm.nih.gov]
  • The precise site of bleeding, etiology, and pathogenesis have not been previously identified.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Colonic diverticulosis was associated with direct inguinal and umbilical/epigastric hernia repair suggesting that connective tissue alterations, herniosis, could be a common etiologic factor of colonic diverticulosis and these abdominal wall[ncbi.nlm.nih.gov]
  • Etiology The etiology of colonic diverticulosis is multifactorial and not entirely known.[merckmanuals.com]
  • […] indentations and narrowing of lumen of colon TOP DIFFERENTIAL DIAGNOSES • Giant sigmoid diverticulum Represents chronic, walled-off abscess that communicates with colonic lumen • Diverticulitis Due to perforation of 1 or more diverticula PATHOLOGY • Etiology[radiologykey.com]

Epidemiology

  • PURPOSES: Colonoscopic evidence of epidemiological trends in diverticulosis and diverticular bleeding is scarce. We evaluated trends in diverticular disease and associated factors over 9 years.[ncbi.nlm.nih.gov]
  • BACKGROUND: The possible relationship between obesity and the risk of colonic diverticulosis has been suggested by recent epidemiologic studies, although the results were inconsistent.[ncbi.nlm.nih.gov]
  • Despite sharing common epidemiologic predisposing factors, the association between diverticulosis and colon polyps remains unclear and needs better clarification.[ncbi.nlm.nih.gov]
  • Diet and other factors in the aetiology of diverticulosis: an epidemiological study in Greece. Gut 1985;26:544–9. PubMed Google Scholar 14. Painter NS.[link.springer.com]
  • Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights. Am J Gastroenterol 2012; 107:1486–1493. 7. Colecchia A, Sandri L, Capodicasa S, et al.[journals.lww.com]
Sex distribution
Age distribution

Pathophysiology

  • Further studies are needed to investigate this association and its putative pathophysiological mechanisms.[ncbi.nlm.nih.gov]
  • Furthermore, we provide an overview of pathophysiology, diagnosis and therapeutic options.[ncbi.nlm.nih.gov]
  • BACKGROUND AND AIMS: Although the pathophysiologic basis of colonic diverticular disease is understood incompletely, there is agreement that abnormal colon motility probably plays a major role.[ncbi.nlm.nih.gov]
  • […] peridiverticulitis in 1907 and underlined the difficulties in distinguishing diverticular disease from malignancy. 11 Telling and Gruner's classic paper describing complex diverticular disease was not published until 1917. 12 At this time the prevalence and pathophysiology[accesssurgery.mhmedical.com]
  • Banerjee S, Akbar N, Moorhead J, Rennie JA, Leather AJ, Cooper D, Papagrigoriadis S: Increased presence of serotonin-producing cells in colons with diverticular disease may indicate involvement in the pathophysiology of the condition.[karger.com]

Prevention

  • RECENT FINDINGS: High-fiber diet does not prevent diverticulosis occurrence, and results about prevention/treatment of diverticular disease and acute diverticulitis are still conflicting.No association was seen between nut, corn or popcorn consumption[ncbi.nlm.nih.gov]
  • Diet high in fiber increases stool bulk and prevents constipation, and theoretically may help prevent further diverticular formation or worsening of the diverticular condition.[medical-dictionary.thefreedictionary.com]
  • Further studies are warranted to determine ways to prevent enteric peritonitis in PD patients with diverticulosis.[ncbi.nlm.nih.gov]
  • Increasing fiber in the diet may help to bulk the stools and prevent the formation of new diverticuli, diverticulitis, or diverticular bleeding. Fiber is not proven to prevent these conditions.[nuh.com.sg]

References

Article

  1. Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease. Radiographics. 2000;20(2):399-418.
  2. Feuerstein JD, Falchuk KR. Diverticulosis and Diverticulitis. Mayo Clin Proc. 2016;91(8):1094-1104.
  3. Weizman AV, Nguyen GC. Diverticular disease: Epidemiology and management. Can J Gastroenterol. 2011;25(7):385-389.
  4. Hobson KG, Roberts PL. Etiology and Pathophysiology of Diverticular Disease. Clin Colon Rectal Surg. 2004;17(3):147-153.
  5. Salzman H, Lillie D. Diverticular disease: diagnosis and treatment. Am Fam Physician. 2005;72(7):1229-1334.
  6. Boynton W, Floch M. New strategies for the management of diverticular disease: insights for the clinician. Therap Adv Gastroenterol. 2013;6(3):205-213.

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Last updated: 2019-07-11 20:51