Diverticular Disease

What are diverticula?

Diverticula are small pouches on the wall of the bowel that form as a consequence of increased pressure within the bowel. This can be due to spasm of the muscular layer of the bowel and/or chronic constipation.

What happens then?

Faeces can get stuck into the diverticula and cause chronic or acute inflammation. Recurrent episodes of inflammation can produce extensive fibrous scar tissue within and around the colonic wall and this will lead to progressive stricture with constipation up to complete obstruction. Acute inflammation with or without perforation of the bowel can cause a life-threatening peritonitis.

Can diverticula be only in the large bowel?

Not at all. There are diverticula virtually in every part of the digestive tract, from the oesophagus to the large bowel. For the sake of clarity, we will discuss only of diverticula of the large bowel.

What are the symptoms of diverticula?

In very most of cases diverticula are asymptomatic. Sometimes, patients complain of constipation and vague niggling pain in the left lower part of the abdomen. These symptoms may not be due to diverticula, but to the basic abnormality that actually led to diverticula. Acute diverticulitis present with fever and pain in the left lower abdomen. In case of diverticular perforation, the patient develops peritonitis, with acute stabbing abdominal pain, fever, general malaise. Sometimes, patients present with gradual or sudden increasing constipation, up to a complete bowel obstruction.

Clearly, before any treatment, it is necessary to do some investigation, isn’t it?

Yes, it is. Even if an episode of pain in the left lower abdomen with fever and general malaise in an adult patient may be probably due to acute diverticulitis, this diagnosis must be confirmed with some investigation. The same is true for any kind of abdominal symptom. Unfortunately, symptoms of diverticula often overlap those of a cancer of the bowel, so a good visualization of the large bowel is mandatory. Apart from the usual blood test, to rule out any acute inflammation or sepsis, in emergency the best first test is CT scan of the abdomen. This can confirm the presence of diverticula and identify any complication, such as perforation or abscess. A camera test – colonoscopy – or a CT-colonography can be necessary in case of recurrent diverticulitis (keeping in mind that it is sensible to avoid colonoscopy during the acute episode of diverticulitis) or in case of chronic symptoms such as constipation or pain. Barium enema is quite an old-fashioned investigation that can be still useful in particular if we suspect a diverticular stricture of the bowel.

How can they be cured?

Diverticula don’t need to be cured unless they are symptomatic or complicated. Much more important is to try and prevent inflammation of the diverticula, which is mostly avoiding constipation. This can be cured with laxatives and a good diet, rich of water and vegetables. There is still debate within the medical and surgical communities on whether inflammation can be avoided with the preventive use of medications such as antibiotics and anti-inflammatory drugs. Acute inflammation – diverticulitis – definitely needs antibiotics. If there is an abscess, this must be drained with a imaging-guided approach, with laparoscopy or with open surgery. In case of peritonitis or bowel obstruction, an emergency surgical operation is necessary. In case of recurrent episodes of acute diverticulitis or progressive stricture of the bowel, an elective bowel resection should be considered.

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