colon diverticula and diverticulosispletely normal. frequently, however, a pressure sensitive colon,...

Colon Diverticulaand Diverticulosis

The informed patient

Revised

edition 2005

Dr. K. WehrmannProf. Dr. P. FrühmorgenKlinikum Ludwigsburg, Germany

DR. FALK PHARMA GmbHLeinenweberstr. 5Postfach 652979041 FreiburgGermany

Publisher

© 2005 Dr. Falk Pharma GmbHAll rights reserved. 6th revised edition 2005


K. Wehrmann andP. Frühmorgen, Ludwigsburg (Germany)

Colon Diverticulaand Diverticulosis

Authors:

Dr. K. WehrmannProf. Dr. P. FrühmorgenMedizinische Klinik IGastroenterologie/HepatologieKlinikum LudwigsburgD-71640 LudwigsburgGermany


3

Contents

page

I. Introduction 5

II. Frequency and localization 7of diverticula

III. Causes and development 9of diverticula

IV. Symptomatic diverticulosis 10

V. Diverticular disease 121. Diverticulitis 122. Bleeding 143. Fistulae 144. Perforation 155. Stenosis 15

VI. Diagnosis 161. Radiological examinations 162. Colonoscopy 203. Ultrasound and computed 22

tomography

VII.Therapy 241. Conservative treatment of 24

diverticulosis2. Conservative treatment of 28

diverticulitis3. Surgical treatment of diverticulitis 30

Acknowledgement

We wish to express our sincere thanks toProf. Dr. J. Treichel, Institute for DiagnosticRadiology of the Klinikum Ludwigsburg. Prof. Dr. M. Stolte, Institute for Pathology,Klinikum Bayreuth provided the illustration of thecolon specimen with diverticulum (figure 1).


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I. Introduction

Diverticula can occur at any point in the gastroin-testinal tract (esophagus, stomach, small boweland colon). We distinguish between congenitalor inborn diverticula and diverticula that have beenacquired at some point in life. They are particularlyfrequent in nations with a high standard of livingand constitute one of the so-called diseases ofcivilization.

Diverticula of the colon are, in most cases, ac-quired outpouchings of the mucosal layer of thebowel through gaps in the bowel wall muscula-ture (figures 1 and 2).

Figure 1: Surgical specimen of the colon including a diverticulum.

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Diverticulosis describes the presence of multiple,non-inflamed diverticula, but says nothing abouttheir localization or the patient’s symptoms.

Diverticulitis is defined as the inflammation of oneof more diverticula. The inflammatory processmay be limited to the immediate vicinity of thediverticula or may extend to surrounding struc-tures and organs.

The term diverticular disease is applied to thatcondition in which diverticula are symptomatic,inflamed or there are complications.

Figure 2: Schematic representation showing the development of adiverticulum. The left side shows normal conditions, while, on theright, one sees a diverticulum, which is an outpouching through avascular gap in the musculature.


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II. Frequency and localization of diverticula

The importance of diverticular disease has beenrecognized since the 1930’s. Since then, diverticu-losis with its potential complications is consideredthe most common bowel disease in the Westernworld.With advancing age, there is a significant increasein the frequency of diverticula (figure 3). Whileless than 10% of persons aged 30–40 years sufferfrom diverticula, this proportion rises to 20–35%in persons aged 50–60 years, increasing to over40% in persons over 70 years of age. With ad-vancing age, there is increase in both the numberand size of diverticula. Men and women are aboutequally affected.

20 40 60 80 100

60

50

40

30

20

10

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Pre

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ivert

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%)

Age in years

Figure 3: Frequency of colonic diverticula in relation to patients’ age.

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The colon (figure 4) consists of the caecum withappendix, the ascending, transverse and descend-ing colon, the S-shaped sigmoid colon and therectum. The sigmoid colon is the bowel segmentmost frequently affected by diverticula (80–95%).The second most commonly affected segmentof the colon is the descending colon, followed infrequency by the other segments. Although alarge percentage of the population develops diver-ticula at some point in their lives, over 80% ofthese people remain asymptomatic.

Figure 4: Segments of the colon.

Transverse colon

Ascending colon Descending colon

Cecum

AppendixSigmoid

colon

Rectum


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III. Causes and development of diverticula

Although the exact causes remain unknown, it istoday considered very probable that diverticulosisresults primarily from segmental motility distur-bances in the colon that result in localized areasof high intra-luminal pressure within the bowel.Further factors include acquired weakness of thebowel wall in the area of vascular and musculargaps (figure 2) and changes in lifestyle and nutri-tional habits.

In particular, reduction in dietary intake of high-fiber foods and their substitution with food withlow fiber content appears to play an importantrole in the development of diverticula. In regionssuch as South-East Asia and Africa with nativediets high in dietary fiber, diverticula is only rarelyreported.

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IV. Symptomatic diverticulosis

Non-inflamed diverticula typically cause no symp-toms by themselves; for this reason, the majorityof persons affected by diverticula remain com-plaint free throughout their lives. Instances inwhich persons do experience lower abdominalpain are generally due, not to the diverticula, butto simultaneous bowel spasticity.

Patients complain of pulling or cramping abdomi-nal pains, most commonly centered in the leftlower abdominal quadrant. Patients complain oftearing or colicky abdominal pain, usually involv-ing the left lower abdominal quadrant. This pain,secondary to a cramp-like motility disturbance ofthe bowel, may resolve within a few hours, butmay go on for several days. Food intake may befollowed by an increase in symptoms due to en-hanced motility, while defecation and passage offlatus may bring improvement or even resolutionof complaints. The constellation of meteorism,tenesmus, flatulence and stool irregularitiespoints to a connection to, or simultaneous pres-ence of, irritable bowel syndrome.

The patient’s physical examination may be com-pletely normal. Frequently, however, a pressuresensitive colon, an abdomen distended by gas ora ”palpable and pressure sensitive roll“ may benoted in the left lower quadrant. Laboratory para-meters are within normal limits (table 1).


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Table 1: Symptoms and findings of irritable bowel syndrome withand without diverticulosis.

Symptoms • Tenesmus• Meteorism• Stool irregularities• Feeling of fullness• Changing localization and

intensity of complaints withsymptom-free intervals

Findings • Gas-distended abdomen• Palpable ”roll“ in the lower

abdomen• Pressure-sensitive colon• No derangement of laboratory

parameters

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V. Diverticular disease

1. Diverticulitis

The most common complication of diverticulosisis the inflammation of the diverticula (diverticulitis),which occurs in about 20% of cases. Thought totrigger this inflammation is the entrapment of stoolparticles (fecoliths) in the diverticula (figure 5a),the constant pressure of which can lead to theformation of tiny ulcerations within the area ofthe diverticula (figure 5b).

If the inflammatory process extends to the entirebowel wall and even into adjacent organs, patientsmay experience serious complications such asabscess formation, peritonitis and the develop-ment of fistulae to adjacent organs, includingother bowel segments and even the urinary blad-der and vagina. Repeated bouts of inflammationin the diverticula can lead to formation of scartissue with increased narrowing of the bowel(stenosis). Ultimately, obstruction of the bowelmay develop and require surgery.

Figure 5a: Fecolith within adiverticulum.

Figure 5b: Pressure ulcer at themargin of a diverticulum.


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The inflammation of one or more diverticulamanifests itself in the form of acute, usuallycolicky pain centered in the left lower abdominalquadrant. In addition, patients may experiencefever, irregular stools (constipation, less oftendiarrhea), as well as nausea, vomiting and re-duced general health.

If the bladder region is affected by the inflamma-tory process, patients may experience difficultyin urinating or having urinary urgency. In somecases, there may actually be visible blood in theurine (table 2).

The findings of the physical examination by thephysician during the phase of acute inflammation(diverticulitis) reveals a distended and pressure-sensitive abdomen. The most commonly affect-ed bowel segment is the sigmoid colon, locatingin the left lower abdomen, which can be felt as a

Symptoms • Spontaneous pain• Tenesmus• Stool irregularities

(constipation/diarrhea)• Fever• (Rectal bleeding)• (Painful urination)

Findings • Palpable ”roll“ in the lowerabdomen

• Pressure-sensitive colon• Guarding• Bloated abdomen• Leukocytosis• ESR acceleration

Table 2: Symptoms and findings in acute diverticulitis.

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painful ”roll“. Depending on the extent of the in-flammatory process, there may also be a limitedinflammation of the peritoneum (the inner liningof the abdomen) with associated guarding.Laboratory tests show a moderate to significantleukocytosis or increase in the number of whiteblood cells (leukocytes) and of the erythrocytesedimentation rate (ESR).

2. Bleeding

Rectal bleeding may also be due to diverticula.Significant bleeding is usually associated withnon-inflamed diverticula of the ascending colon,while smaller amounts of blood are observed withinflamed diverticula. The duration and intensity ofthe bleeding can be variable. Bleeding stopsspontaneously without therapeutic measures inover 80% of cases. About one-quarter of thesepatients, however, experience recurrent bleeding.

3. Fistulae

Another complication of diverticulitis is fistulation,or the formation of fistulae, which are incompleteor complete ductal structures linking the bowelsegment affected by diverticula with other bowelsegments. Fistulae may also form between thebowel and adjacent organs, such as the urinarybladder and vagina. In these cases, patients mayexperience the escape of flatus or stool throughthe urethra or vagina.


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4. Perforation

Sometimes, diverticulitis is associated with per-foration of a diverticulum. In most cases, this isnot associated with acute peritonitis (inflamma-tion of the peritoneum) because superposedadjacent bowel loops act to seal the defect.Perforation may begin with discrete areas of ab-dominal pain or patients may be initially asympto-matic. The escape of intestinal contents througha perforated diverticulum is a rare event, but,when it does occur, it is associated with an acuteand dramatic clinical picture. In these cases, pa-tients may experience the severe complicationsof generalized peritonitis.

5. Stenosis

The inflammation of diverticula can result in nar-rowing of that section of the bowel. If inflamma-tion is extensive or recurs, scar tissue may form,resulting in increased thickness of the bowel walland narrowing of the bowel (stenosis). Becausesuch narrowing does not resolve, the ultimate re-sult may be complete obstruction of the bowel,which may require surgical therapy.

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VI. Diagnosis

Diverticula are common coincidental findings ofradiological or endoscopic (colonoscopic) exami-nations. Symptoms of lower abdominal pain withfever and an increase in the white blood cellcount point to the possibility of acute diverticuli-tis, among other diagnoses. Consultation of aphysician is essential. The type and extent of thework-up depends on the patient’s symptoms.This means consideration of all possible disordersand the appropriate tests to rule them in or out.

1. Radiological examinations

Radiological examination of the colon using doublecontrast technique has been largely discontinuedin the work-up of diverticulosis. Diverticula appearas circumscribed, contrast-enhanced outpouch-ings of the intestinal wall (figure 6). They maycontinue to be visible for days after the initial ex-amination as round or oval structures filled withcontrast medium, ranging in size from a pea to ahazelnut (figure 7).

Figure 6: Radiograph showing extensive diverticulosis.

Changes in the mucosal surface, narrowing of thebowel and absent motility in an area of the bowelknown to be affected by diverticula can all besigns of acute or chronic diverticulitis (figure 8).

Radiological examination by itself cannot defini-tively determine whether narrowing of the bowel(stenosis) in a patient with known diverticula isdue to inflammation or whether it may actuallybe caused by a tumor. In such cases, endoscopy(colonoscopy) with biopsy (tissue sampling) mustbe part of further work-up. The development of


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Figure 7: Radiograph obtained 72 hours after contrast mediumenema. Contrast medium can still be seen in the diverticula.

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fistulae (figure 9), a possible complication of di-verticulitis, can also be identified radiologically. Incases of bleeding from diverticula, simple radio-logical imaging of the colon is not useful: Here,dye is injected into an artery, permitting visualiza-tion of the vessels (angiography). If the bleedingis of sufficient quantity, the source of bleedingcan be identified as a site of contrast mediumescape into the bowel lumen (figure 10).

Figure 8: Radiological evidence of acute diverticulitis (arrows) usingwater-soluble contrast medium.


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Figure 9: Radiological visualization of an incom-plete fistula (arrow) in a patient with diverticulitis.

Figure 10: Radiological visualization (angiography) of the vesselssupplying the colon in a patient with diverticular bleeding. At the siteof bleeding, one sees a cloud-like structure representing escape ofcontrast medium into the bowel lumen (arrows).

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2. Colonoscopy

Diverticula are easily recognized by endoscopicmethods (figure 11). As a rule, colonoscopy isnot performed during the acute phase of divertic-ulitis because the risk of injuring the bowel dur-ing the phase of acute inflammation is too high.Sometimes, inflamed diverticula cannot be seenon endoscopy. In such cases, however, one usu-ally finds swelling and redness of the mucosalmembrane at the neck of the diverticulum as asign of inflammation (figure 12).Intestinal polyps located in segments of thebowel affected by diverticula are also more reli-ably detected by endoscopy than by radiologicexaminations. If the distance between the polypand the diverticular opening is sufficiently large,polyps can usually be safely removed duringcolonoscopy (figure 13).A further advantage of endoscopy is the detectionand localization of diverticular bleeding (figure 14a),whether this is a slight ooze from an inflameddiverticulum or massive bleeding from non-in-flamed diverticula. Besides identification of ableeding site, it may in many cases be possibleto stop the bleeding by, for example, injectingmedications to constrict the vessels (figure 14b).

Figure 11: Endoscopic findings of extensive diverticulosis.


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Figure 12: Endoscopic findings of acute diverti-culitis.

Figure 13: Endoscopic evidenceof diverticula and a polyp in thesame bowel segment (sigmoidcolon).

Figure 14a: Endoscopic evi-dence of diverticular bleeding.

Figure 14b: Endoscopic proce-dure to stop diverticular bleedingby injection of dilute epinephrinesolution.

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3. Ultrasound and computed tomography

Formerly, abdominal ultrasound and computedtomography (CT) were used only for demonstra-tion or exclusion of serious complications inpatients with diverticulitis, such as abscesses or conglomerate tumors (significant inter-loopadhesions of the bowel).

With increasing experience and the introductionof high-resolution ultrasound scanners, diagnosticultrasound can provide reliable information onthe thickness of the bowel wall, the presence of asymptomatic diverticula, evidence of divertic-ulitis and other complications of diverticulitis (figures 15, 16a and 16b). Thus, ultrasound hastaken an established place besides physical ex-amination and laboratory tests in the initial work-up of diverticulitis.

Figure 15: Computed tomography findings of an abscess (arrows)in the lower abdomen as a consequence of a perforated diverticu-lum in a patient with acute diverticulitis.


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In addition, both ultrasound and CT provide theoption of guided puncture to confirm the diagno-sis in cases in which an abscess is suspected andthis can be followed by evacuation or drainage asa definitive therapeutic measure. This may avoidsurgery or obviate the need for multiple surgicalprocedures. Ultrasound also provides a meansfor regular monitoring of the clinical course ofdiverticulitis without exposing the patient to un-necessary radiation or discomfort.

Figure 16a

Figure 16b: Ultrasound findings in a patient with acute diverticulitis:thickened bowel wall with a diverticulum in longitudinal section (figure 16a) and transverse section (figure 16b).

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VII. Therapy

While patients with asymptomatic diverticulosisdo not require medical or surgical therapy, thosewith diverticular disease can be offered conser-vative or surgical treatment options that differwith the patient’s symptoms and the extent ofthe inflammation.

1. Conservative treatment of diverticulosis

Patients with diverticulosis and functional com-plaints (abdominal cramps, bloating, stool irregu-larity, feeling of fullness) without evidence ofinflammation are advised to adopt a high-fiberdiet including the use of wheat bran (table 3).

Dietary fiber consists of substances that act asbulking agents because of their ability to bindwater without being digested by the humanbody. Common types of fiber include cellulose,the hemicelluloses, pectins, lignin, indigestiblepolysaccharides and alginates. The physical prop-erties of these substances are very diverse butall share the capacity to increase the stool mass,reducing pressure in the bowel and shorteningthe stool transit time in the bowel. Besides whole

Table 3: Treatment of diverticulosis with functional complaints.

• High-fiber diet• Wheat bran• Other bulking agents• Adequate fluids• Moist-warm compresses• Lactulose (for constipation)• Medications that relieve cramps


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grain products, important sources of dietary fiberinclude vegetables, potatoes, salads, fruit, andgrains (table 4).

Fruits grams of fiber per100 grams

Apples 0.9Bananas 0.6Blackberries 4.1Currants 3.4Dates 2.3Elderberries 6.8Kiwi 1.1Oranges 0.5Pears 1.5Pineapple 0.5Plums 0.7Raisins 0.9Raspberries 3.0

Grains and grams of Baked goods fiber per

100 grams

Millet 3.2Oatmeal 1.4Rice 0.9Rye 1.7Wheat 2.1(whole wheat flour)

Fibre content per 100 g edible material

Graham crackers 1.1

Pasta 0.3Rolls 0.3Rye bread 1.5Wheat bread 0.9

Vegetables grams of fiber per100 grams

Artichokes 2.4Beans 1.0Broccoli 1.5Cabbage 1.3Cauliflower 1.0Corn 0.7Lentils (dried) 3.9Lettuce 0.5Peas 2.0Potatoes 0.5Sauerkraut 0.7Soy beans (dried) 4.9

Tomatoes 0.5

Table 4: Fiber content of some foods (from: WissenschaftlicheTabellen Geigy, 1985).

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In addition, with adequate fluid intake (1.5–2.5 litersper day), patients can take 10–25 grams of wheatbran. A comparison of fiber derived from differ-ent foods has shown that wheat bran causes thegreatest increase in stool weight. The effect ismost pronounced when wheat bran is coarseand not finely milled. Untreated brans also have a greater effect than do cooked brans.

Patients with a tendency to constipation requiregeneralized measures (table 5). Good-tastingmuesli preparations (table 6) are recommended. In place of white bran, the pharmaceutical indus-try has introduced numerous effective bulkingagents such as karaya gum, Plantago ovata etc.The daily dose of an agent such as Plantago ovataseed shells is 5–15 grams per day. High-fiber dietand bulking agents may take weeks or months of regular use to produce any improvement insymptoms. Adequate fluid intake of 1.5–2.5 litersper day is essential.

The activity of the colon is also affected by thetype of beverage. While coffee, mineral waterand fruit juice stimulate passage of stool, blacktea, cocoa, and red wine may cause or worsenconstipation.


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• Before breakfast, take a glass of cool water containinga level teaspoon of magnesium sulfate (or sodiumbicarbonate). Gradually reduce use as constipationimproves.

• For breakfast, four heaping tablespoons of oatmeal andfour heaping tablespoons of wheat bran, together withone tablespoon of lactulose and cold milk. Mix well.

• For breakfast, whole grain bread, if desired with prunejam and herbal tea (peppermint, rose hips, mallow). If desired, bean coffee prepared as espresso.

• After breakfast, spend the next 5–10 minutes in thebathroom and attempt to pass stool. It is important torelax and not press excessively. Be patient if you arenot successful the first few times.

• For your main meals, include much high-fiber food(salads, radishes, cucumbers, sauerkraut, oranges, apples, nuts or dried apricots and plums).

• Protein-containing foods that are recommended includesour milk, kefir and yogurt. Alcoholic beverages includedry white wines (Mosel, Franconia), if desired, withhigh-magnesium mineral waters.

• Physical exercise and occasional massage of the backand abdomen.

• Adequate fluid intake, especially in older persons(11⁄2–21⁄2 liters per day)

• 1–2 pouches of Macrogol per day.

• 1–6 tablespoons of lactulose.

• Constipation is promoted by low-fiber foods (too littlefruit and salads, white bread and sweets), chocolate,red wine, strong black tea and codeine-containingpharmaceuticals (analgesics, cough remedies).

Table 5: Basic treatment of chronic constipation (alternative options).

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Patients with cramping abdominal pain often getrelief from moist warm compresses on the ab-domen (hot-water bottle with moist towel).

Your physician may temporarily prescribe med-ication that will relieve the cramps. Analgesicsshould only be used for short periods and onlyafter consulting your doctor.

2. Conservative treatment of diverticulitis

Non-complicated acute diverticulitis can be treat-ed conservatively (i.e., without surgery) in thegreat majority of cases. For better monitoring ofthe patient and in order to quickly recognize com-plications, this treatment normally requires hos-pitalization. Initially, patients are placed on bedrest, absolute avoidance of any food by mouth

Muesli recipe

• One-half cup of all-purpose muesli• One cup of yogurt• One teaspoon of pine seeds• One teaspoon of ground hazelnuts• One teaspoon of sunflower seeds• One-half teaspoon of sesame seeds• One-half teaspoon of oatmeal• One teaspoon of raisins• Two teaspoons of grated apple• One teaspoon of honey• Juice from one half lemon

Mix ingredients and eat for breakfast.

Table 6: Muesli recipe for the treatment of constipation.


29

and replacement of fluid through an intravenouscatheter (table 7).

In addition, spasmolytic medication or analgesicsmay be temporarily required. In general, patientsalso undergo 7–10 days of antibiotic therapy.

The majority of patients become free of com-plaints after only a few days of this therapy.Regular laboratory and ultrasound monitoring to-gether with physical examinations are necessaryin order to promptly recognize complications(bleeding, abscess formation, perforation, fistula-tion etc.). In mild cases, diet may be advancedrapidly with tea and crackers or by use of a liquiddiet that is completely absorbed in the uppersmall bowel. As the inflammation subsides andpatients’ complaints resolve, a high-fiber dietincluding bulking agents can be started. Mildbleeding in cases of acute diverticulitis normallyresolves spontaneously without need for surgery.About one-half of all patients experience recur-rent inflammatory episodes, with some of thesepatients ultimately requiring surgery.

If diverticulitis recurs frequently, especially inelderly persons or in patients with other seriousdisease, long-term antibiotic treatment may rep-resent an alternative to surgery. Studies have

Table 7: Treatment of non-complicated acute diverticulitis.

• Fasting• Parenteral nutrition• Antibiotics• Analgesics• Spasmolytics (cramp-relieving medications)

30

shown that the addition of anti-inflammatorymedications may also reduce the rate of inflam-matory episodes.

3. Surgical treatment of diverticulitis

Diverticulosis in patients with primarily asympto-matic disease is never an indication for surgicaltherapy except in rare cases of massive hemor-rhage that cannot be controlled with conservativemeasures.Perforations, abscess formation and intestinalobstruction as complications of diverticulitisrepresent emergent indications for surgery. Alsoconsidered absolute indications for surgery arefistulae and cases in which carcinoma of thecolon cannot be definitively excluded from thedifferential diagnosis.

Inadequate response to antibiotic therapy in casesof acute inflammation, repeated episodes ofdiverticulitis, and bleeding, as well as problemswith urination, may also be considered indica-tions for a surgical approach (table 8).

A rule of thumb is that surgical removal of theaffected bowel segment should occur if a patientexperiences two episodes of diverticulitis withinone year or three episodes within three years.Some centers even recommend surgery afterthe first episode. In any case, the decision forsurgery must weigh all individual factors.The success of an operation is dependent to agreat extent on selection of the optimum time.This requires use of clinical and imaging methodsfor determining of the most appropriate time forsurgery when the risk to the patient is lowest.


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At the same time, care is taken to spare patientsthe burden of multiple operations, which used to be common in such cases.

In some instances of emergency surgery it willbe necessary to create an artificial outlet for thebowel. In most cases, however, the normalcontinuity of the bowel can be re-established by means of a second operation within a fewweeks.Abscesses that form in the abdominal cavity cantoday often be reduced or drained by means of apuncture needle inserted through the skin underultrasound or computed tomographic guidance.These methods continue to reduce the numberof operations. Larger abscesses, however, mustgenerally be treated surgically.

Emergent indications for surgery

• Perforated diverticula with peritonitis and/orabscess formation

• Bowel obstruction• Fistulae• Suspected colon cancer

Potential indications for surgery

• Persistent complaints despite therapy• Repeated episodes of inflammation• Repeated bleeding• Persistent problems with urination

Table 8: Emergent and potential indications for surgical treatmentof diverticulitis.

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colon diverticula and diverticulosispletely normal. frequently, however, a pressure sensitive colon,...

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