Diverticular Disease and Diverticulitis

Diverticular Disease and Diverticulitis

What is diverticulitis?

Diverticula in the colon.Diverticula, small marble-sized blisters or sacs (pouches), which form in the lining of the colon (commonly found in the lower portion of the large intestine, just before the rectum) or small intestine can develop, when this occurs the condition is termed diverticular disease. When these pouches become inflamed and infected, diverticulitis (pronounced die-vur-tik-yoo-LIE-tis), a gastrointestinal condition, occurs and can be painful. Diverticular disease is regarded as a chronic condition, which requires lifelong management. Flare-up attacks may or may not occur following the first experience, which largely depends on a person’s state of health and how well measures to prevent complications are maintained.

Blisters or sacs form when the inner layer of the digestive tract is forced through weak areas in the outer layer. Diverticula can, theoretically, occur anywhere between the mouth and the lower portion of the large intestine (colon), where blood vessels run through the intestinal wall.

These blisters may occur without infection and are most common in individuals over the age of 40 (rarely causing any problems). Many with uninfected blisters may be oblivious to having them as no symptoms are present. The condition in this instance, is known as diverticulosis. To date, it is not fully understood why some diverticula become infected and others do not.

Infected diverticula may occur anywhere in the digestive tract. A tell-tale sign is a painful sensation in the lower left side of the abdomen, and rectal bleeding. Most often pain and bleeding is accompanied by other signs of infection such as fever, nausea and a distinctive change in normal bowel movements.
Diverticulitis is a treatable condition, but a person can experience recurring infections and / or diverticulosis (diverticular disease). The disease can be mild or severe (recurring), and is treated accordingly.

Illustration showing the difference between diverticulosis and diverticulitis.

What happens to the body?

A mild infection with the presence of few symptoms can sometimes resolve itself without treatment intervention. A sudden pain, most commonly felt on the lower left side of the abdomen often signals severe diverticulitis. Pain is typically persistent and worsens during the course of a few days if treatment is not sought out.

Many may also experience pain in the lower abdomen while recovering from a diverticulitis attack. This may not always indicate another attack, but is best examined by a medical doctor.

Symptoms of diverticulitis

Close-up on a young woman experiencing stomach pain or discomfort.As mentioned, diverticulosis does not typically present symptoms. Once an infection occurs, ‘non-specific symptoms’ (meaning those that are commonly found in an array of different digestive disorders) of diverticulitis develop.

Along with lower abdominal pain and tenderness, the following are typical symptoms of diverticulitis:

  • Nausea and / or vomiting
  • Fever and / or chills
  • Bloating (abdominal swelling or abdominal distension) and / or flatulence (gas)
  • Cramping
  • Diarrhoea
  • Constipation
  • Lack of appetite
  • Mild rectal bleeding (bright red or maroon in colour, or clots)

It can happen that a fistula (an abnormal opening or connection between tissues / organs) develops between the colon and the urethra. If this occurs, air or stool (faeces) may be passed from the urethra, causing similar symptoms.

Other conditions which may also cause similar symptoms include a urinary tract infection or irritable bowel syndrome (IBS).

When to see the doctor?

Any symptoms experienced should be checked by a medical doctor. Inflammation in the body can worsen and cause a variety of other health complications, which can become serious. Any bleeding noted in stool or from the rectum must be examined by a medical professional. A doctor needs to check this even if bleeding stops or resolves on its own, and especially so if a steady flow of blood is experienced (which will require emergency examination).

A doctor will deem a person’s condition serious, especially if any of the below is experienced (for at least 3 days or more):

  • Persistent abdominal pain which worsens or intensifies when moving or coughing (especially in the lower left side)
  • A persistent fever
  • Persistent vomiting (a person cannot tolerate any amount of food or liquid)
  • A burning or painful sensation during urination
  • Gas or stool that passes through the urethra while urinating
  • Persistent cramping which does not ease after a bowel movement or passing of gas (flatulence)
  • Bleeding from the rectum and blood (a considerable amount that is more than a few streaks) in stool (faeces)
  • Stool that resembles black tar
  • Persistent constipation (which occurs for an extended period of time)
  • Signs of shock such as fainting, dizziness, weakness and lack of alertness (may indicate that a blister or sac is bleeding, known as diverticular bleeding)
  • An abnormal vaginal discharge
  • Unexplained loss of weight
  • Persistent or recurring urinary tract infection

Who to see

Mild bloating, belly aches and gas pressure are normal after eating certain foods or while under a little stress. If these symptoms do not pass within a few days or worsen, it is best to consult a family physician (general practitioner / GP) to assess the root of the symptoms and diagnose accordingly.
Other than an GP, medical professionals who can all diagnose and offer appropriate treatment for diverticulitis are:

  • A Physician’s assistant
  • Nurse practitioner
  • Internist
  • Specialists – Gastroenterologist or surgeon

What causes diverticulitis?

Processed foods - hot dogs on a plate.A direct cause is not yet entirely known among medical professionals. It is known, however, that a diet lacking in fibre has a strong connection with the formation of blisters and sacs.

A diet that is sufficient in fibre and enough water (hydration) makes for softer stools which are more comfortable to pass. A lack of this causes constipation which results in more pressure in the colon.

This pressure is believed to have a strong influence in the formation of pouches, sacs and blisters (forming when a tear or small perforation in the intestinal wall tissues occur), which then become inflamed with bacterial growth, and lead to diverticulitis. This coupled with uncoordinated movements in the colon results in the formation of the disease.

If an infection results in the further spread of inflammation, peritonitis can occur. This is an infection in the lining of the abdominal wall as a result of diverticula rupture (bacteria and other bowel contents spill into the abdominal cavity).

Risk factors and complications

Factors which place a person at risk of developing diverticulitis include:

  • Lack of fibre content: This is of particular concern for countries that consume high quantities of processed foodstuffs. The average person required at least 5 servings of fresh fruits, vegetables, whole grains and beans for a sufficient amount of fibre every day.
  • Constipation: Strain that occurs on muscles during a bowel movement is associated with a constipated condition. Persistent constipation can create constant strain, which increases risk of inflammation or infection. Bacteria or stool can infect diverticula once formed and lead to a higher risk of diverticulitis.
  • Age: Older generations are more at risk of diverticula becoming infected or inflamed. Research is still yet to determine a distinctive reason why but those between the ages of 40 and 60 do appear more prone to developing the disease. It is believed that bowel weakening during the later years may have a strong influence which contributes to the condition.
  • Obesity: High body mass index (BMI) and waist circumference are factors associated with pressure and inflammation in the body, which can result in diverticular bleeding or diverticulitis.
  • Medication use: The use of NSAIDs (non-steroidal anti-inflammatory medications), steroids, opiates (opioids) and aspirin for extended periods (more than 4 times a week over a period of years).

Other influencing risk factors include:

  • Cigarette smoking
  • Lack of physical activity or exercise
  • A diet that is high in animal fats

An estimated 25% of diverticulitis infections can lead to the following complications:

  • Fistulas
  • Peritonitis (which can also result in organ failure and blood infections if not attended to immediately)
  • An abscess (pus collects in the blisters or sacs)
  • Colon blockages and scarring
  • Sepsis (result of infection spreading through blood)

Diagnosis and treatment

Once at a consultation, a doctor will conduct a short medical interview in order to gain perspective regarding the nature of the visit, as well as acquire a medical history overview.

A doctor will likely ask questions which may include:

  • When did symptoms first begin?
  • How severe are the symptoms being experienced?
  • Are symptoms experienced on a continuous or occasional basis?
  • Has a fever occurred?
  • Are any medications (over-the-counter or prescription) been taken to alleviate symptoms?
  • Are any medications or pain relievers, unrelated to symptoms, currently being taken?
  • Have any measures been taken to alleviate symptoms? If so, what?
  • Have these measures improved or worsened symptoms?
  • Has any pain while urinating been experienced?
  • Has any air been passed while urinating?
  • Has a screening for colon cancer (such as a colonoscopy) ever taken place?

From there, a doctor will request a physical examination and assess the level and location of pain in the abdomen. A doctor may recommend a pelvic exam for all females to rule out any potentially related conditions or diseases. A doctor may also request a digital rectal exam (which involves the insertion of a lubricated, gloved finger in the rectum) to assess possible rectal tenderness and signs of inflammation, or a mass or growth in the lower pelvic area.

Diagnosis and tests

Tests may be recommended to both diagnose and rule out various medical problems or gastrointestinal concerns. Tests will be done as needed and depend entirely on the nature of symptoms, taking severity into account too. One or more of the following may be recommended:

  • Stool sample (faecal occult blood test): This is to determine the pressure of blood in stool (faeces).
  • Urinalysis: This test may be used to determine a urinary tract infection (UTI).
  • Blood test: Diagnostic indicators for infection are usually determined in the analysis of a blood sample which will show a higher than normal white blood cell count and few red blood cells (this is known as a complete blood count or CBC test). Blood tests can also assess any signs of blood loss, as well as check liver and kidney function.
  • Computerised tomography (CT scan): This is to determine whether diverticula which may be infected are present with the use of computer-guided X-ray visuals. A doctor will look for pockets of infection, such as abscesses or a burst diverticulum.
  • Abdominal X-ray: This can help to determine the source of abdominal pain or other related symptoms by checking organs in the abdomen.
  • Barium enema X-ray: This is usually done after a diverticulitis attack due to the risk of peritonitis. This test looks for possible causes of gastrointestinal issues which can help to diagnose symptoms. A substance similar to barium but can be dissolved in water (a water-soluble contract) may be used if diverticulitis is suspected.
  • Colonoscopy or sigmoidoscopy (flexible) screening: If bleeding is one of the symptoms being experienced, this diagnostic test may be able to assess for growths in the intestine or find narrow and weakened spots in the wall lining, using a narrow, flexible tube with a tiny camera attached (inserted through the rectum and passed further up into the colon). The procedure can also help to either diagnose or rule out conditions such as cancer or ulcerative colitis. The procedure is normally not recommended while a person is experiencing a diverticulitis attack due to the risk of causing perforation in the lining of the colon. Symptoms will be carefully assessed before recommending this examination.

In some instances, a pregnancy test may be recommended for women in the reproductive years to check for rule out this as a possible cause of abdominal discomfort or pain.

Medical professional performing a colonoscopy procedure.

Initial treatment for diverticulitis

Next steps, once diverticulitis has been diagnosed, will depend on the nature of symptoms and their severity. Many may be sent home with care instructions. Others may need to be admitted to hospital overnight (or for a few days) for monitoring and treatment.

  • Home treatment: For mild cases, a doctor may recommend bed rest for a few days (up to a week), a liquid diet (to allow for diverticula healing and rest for strained bowels) until solid foods (initially a bland diet that is low in fibre and gradually increased) can be tolerated, and the administration of pain medications and antibiotics to help clear the infection. A liquid diet can include water, ice chips or pops, frozen fruit puree, broth or stock, tea or coffee (without sweeteners, milk or cream) and gelatine. Warm / hot compresses can also be used (as required) to alleviate cramping and abdominal pain.
  • Hospital treatment: Severe cases with signs of complications, such as bowel blockages or an abscess, may require a short stay in hospital (at least one to two days). A doctor will administer intravenous (IV) antibiotics through a vein in the arm and no food or liquids will be given until the infection clears (up to a week). An abscess will be drained using a needle. The stomach may also be drained or emptied by sucking out contents through a tube (nasogastric / NG tube), which is passed through the nose and down the throat into the stomach. Once satisfied that the remainder of treatment can take place at home, a doctor will arrange that the affected person be discharged. Home treatment may take as long as a few weeks (and in some cases months if recurrent attacks occur).
  • Surgery (partial colectomy, bowel resection or colostomy): Recurrent attacks may occur when antibiotic treatment is no longer effective. Surgery may be an option in this instance, when all other treatment measures have failed, as well as when a person has had two or more attacks, or is under the age of 40 and has an impaired immune system, or has developed a complication. Surgery will involve the removal of part of the intestine affected by diverticulitis and reconnecting the remaining parts. A colostomy (wherein the upper intestine is sewn to an opening, called a stoma, that is made in the skin of the abdomen for stool to pass out from and into a disposable bag) may be performed if multiple surgeries are required. Later on, when inflammation has cleared, the intestine is reconnected to healthier portions in a separate surgery, reversing the colostomy. Initial recovery may require a stay of between a few days or a week (sometimes longer) in hospital. A full recovery following surgery may take several months, depending on how well necessary lifestyle changes (such as diet) are implemented. Surgical procedures are rarely required (as many as 6% of all cases).

In the majority of instances diverticulitis treatment shows signs of improvement within 2 to 3 days. Antibiotics should be taken as directed, and a full course completed in order to be effective, even if symptoms reduce significantly before the final dose.

Ongoing treatment

Since diverticulitis can recur (diverticula tend to remain in the system permanently), treatment extends beyond the clearing of infection. Treatment beyond an attack is aimed at reducing the occurrence of another down the line.

A doctor may recommend the following preventive measures:

  • Close-up of quinoa (fibre content)Gradually increasing quantities of fibre into the diet – fresh fruits and vegetables, wheat bran, whole grain breads and cereals, and a fibre supplement.
  • Practice healthy habits – eating at regular times, regular exercise (this helps to reduce pressure in the colon), being mindful of trying to prevent straining during bowel movements and getting plenty of fluids daily (to aid fibre in the absorption of water, thus softening waste in the colon) can all contribute towards healthy bowel function. It is also a good idea to get in the habit of using the toilet whenever the need arises to avoid stool hardening and bouts of constipation.
  • Do not use laxatives to alleviate bowel strain or constipation unless advised and recommended by a doctor directly. Regular use of laxatives can make the bowel ‘lazy’ and encourage function to become dependent on them. Laxatives and enemas can result in more pain and discomfort, and are not generally recommended.
  • Regular check-ups - after an attack and the commencement of treatment, the first follow-up may be requested within 2 days, and thereafter at 6 weeks (these may involve a colonoscopy or barium enema X-ray) and then every so often once symptoms are under control.

What to eat

Great sources of fibre to include in a diet are:

  • Fruit: apples, pears, bananas, oranges, raspberries and mangoes
  • Vegetables: broccoli, carrots, beets, collard greens, cabbage, squash, spinach and sweet potatoes (with the skin), as well as vegetable juices
  • Beans ad legumes: black beans and kidney beans, as well as peas and lentils
  • Whole grains and cereals: brown rice, bulgur wheat, quinoa, and oatmeal

Once the body is clear of infection and a person begins to feel well again following an attack, introducing low-fibre foods into the diet may be recommended. These include:

  • Canned or cooked fruits (without skins or seeds) and vegetables
  • Fruit or vegetable juices (no pulp content)
  • Refined white bread
  • Pasta or noodles and white rice
  • Low-fibre cereals
  • Eggs
  • Fish and poultry
  • Milk, yoghurt and cheese

There are no known trigger foods which specifically cause a diverticulitis attack. Previously nuts, seeds and popcorn were often avoided, but no direct link has been proved through research. It is not advisable to remain on a liquid diet for longer than a handful of days as the body requires more nutrients to function than this will provide. Remaining on a liquid diet for longer can lead to body weakness and will not promote inflammatory healing.

Can diverticulitis become life-threatening?

Normally, once a nutritious diet, rich in fibre, is gradually increased, a person should begin to feel well within as little as a few days. If not, it is strongly advisable to consult the treating doctor for a thorough check-up in order to provide any necessary intervention should any further complications have developed.

Receiving treatment and making necessary lifestyle changes are important for keeping the condition under control. If diverticulitis goes untreated further complications can occur, which can be serious and require surgical procedures to correct. These include the development of an abscess, fistula or obstruction in the intestine.

If any of the below occur, prompt medical attention is required:

  • Peritonitis: infection in the abdominal cavity (peritoneum) due to perforation, which can quickly spread all over the body, and is regarded as severe, becoming life-threatening in a short space of time.
  • Gastrointestinal bleeding: This can range from a small amount to that which is life-threatening. A significant amount of bleeding must be examined by a medical professional in an emergency facility.

What is diverticular bleeding?

Bleeding diverticula can lead to a considerable amount of blood loss, most often present in stools (faeces). Bleeding typically starts suddenly and generally stops on its own, without the accompaniment of abdominal pain.

It is rare, but possible, to lose enough blood that a person becomes weak and lightheaded. Any blood loss noticed must be assessed by a medical professional as soon as possible.

Bleeding generally occurs when blood vessels leading to the small blisters, sacs or pouches break open due to pressure, inflammation or infection. Signs that this has taken place are sudden bleeding (most often without pain) from the rectum that is dark red, maroon or in the form of bright red clots.

Bleeding also stops on its own (but should not be regarded as resolved). Risk for bleeding increases if a person regularly takes aspirin (more than 4 days a week).

Diverticular bleeding may be diagnosed with one or more tests following a physical examination by a medical doctor. These can include a colonoscopy and / or a technetium-labelled red blood cell bleeding scan (a radioactive material called technetium is added to a blood sample and when injected back into the bloodstream can help to trace the source of the bleeding along with an angiography scan).

Treatment depends on the amount of blood lost. Bleeding that does not stop on its own may require hospitalisation and involve the administering of intravenous (IV) fluids, medication injections or blood transfusions. In severe cases, surgery may be necessary to remove infected portions of the colon to prevent further complications.

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