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Diverticulum relates to a thin-walled outpouching of the mucosa and serosa, absent the muscularis.
Diverticulosis refers to the presence of many diverticula, and diverticulitis is defined as inflammation of these diverticula.
Approximately one to 4% of patients with diverticulosis will develop acute diverticulitis in their lifetime, which typically presents his left lower quadrant pain associated with nausea, vomiting, fever, and leukocytosis.
A common occurrence in the hospital setting.
Occurs in up to 25% of patients with diverticulosis, it presents with fever, pain, and a palpable mass in the left lower quadrant.
Diverticulitis refers to the presence of inflammation in diverticula.
Classified as uncomplicated and complicated.
Approximately 85% of people with acute diverticulitis, have uncomplicated diverticulitis without abscess, colon strictures, colon perforation, or fistula formation.
Uncomplicated diverticulitis is defined by localized diverticular inflammation without extracolonic manifestations.
Hypotheses for the pathophysiology of diverticulitis include: fecal matter that may become trapped in the diverticular, micro perforation at the diverticular fundus due to increased luminal pressure from obstruction of the diverticula may stimulate an inflammatory response and diverticulitis, and it may be initiated by changes in the gut microbiome, composition and function, such as decreases in short chain fatty acids in the colon, increases in the invasive pathogenic colonic microbiome and altered bile acids, leading to adverse alterations in mucosal barrier and immune function with subsequent mucosal inflammation.
The annual incidence of diverticulitis in the US is approximately 180 per 100,000 people, resulting in approximately 200,000 hospital admissions annually and an estimated healthcare expenditure of more than $6.3 billion per year.
Hospitalization rates for diverticulitis are increasing because of a disproportionally greater increase in the prevalence of diverticulitis and individuals younger than 50 years.
Hospitalization is particularly increasing among young men with complicated diverticulitis.
People who are immune compromised have higher rates of diverticulitis, and a higher incidence of sepsis.
Diverticulitis, produces symptoms like fever, nausea, vomiting, and pain or tenderness in the lower abdomen.
The most common G.I. tract diagnosis among hospitalized patients are diverticulitis and diverticular hemorrhage.
There are neuropeptide abnormalities and altered histological appearance of muscle and nerves in patients with diverticulitis compared with healthy individuals.
Reduced serotonin transporter expression and fewer interstitial cells of Cajal are found in patients with diverticulitis but not among those with normal colons or with noninflamed diverticula.
80% of patients older than 50 years of age.
Diverticular disease is approximately 70% prevalent in patients aged 80 years or older.
Old age is associated with loss of myenteric plexus neurons resulting in uncoordinated colonic contractions and high intestinal pressure, producing colonic wall outpouchings.
There is an increase in risk in siblings, and in patients with gene variants associated with diverticular disease.
There is also an increased risk of diverticular disease in inherited connective tissue disorders: polycystic kidney disease, Marian syndrome, and Ehlers-Danlos syndrome.
The disease costs approximately $2.4 billion annually in the United States.
Obesity increases the risk of diverticulitis.
Risk factors include: obesity, smoking, medications such as nonsteroidal anti-inflammatory drugs, corticosteroids, and opiates.
Risk factors for diverticular disease include age older than 65 years, genetic factors such as variant in the tumor necrosis factor super family member 15 gene, connective tissue diseases, such as polycystic kidney disease, Marian syndrome, or Ehlers-Danlos syndrome, body mass index, 30 or greater, use of opioids, steroids, and nonsteroidal, anti-inflammatory medications hypertension, and type two diabetes.
Smoking also has been found to be an independent risk factor for diverticulitis.
Increased incidence is accounted for by aging, increased obesity, and the increased incidence of diverticulitis in people with normal BMI.
The prevalence of diverticulitis is increased in individuals with a BMI rated than 30: reducing BMI to less than 25 may reduce diverticulitis incidence.
No established evidence that red meat consumption, alcohol, smoking, consumption of seeds, and nuts, Who specific microbiota are associated with the development of diverticuli.
Physical activity, such as running may be associated with a lower rate of diverticulitis/diverticular disease.
Genetics has been found to play a significant role in the pathogenesis of diverticulitis.
Asian countries and people of Asian ancestry have reported right-sided diverticulosis, while those with Western ancestry have found diverticulosis on the left side of the colon.
Japanese population living in Hawaii following a Western diet still predominantly report right-sided diverticular disease.
Furthermore, only left-sided colonic diverticula was inversely associated with constipation.
The increasing rate of diverticulosis correlates with an increase in the rate of diverticulitis.
Healthy lifestyles and pursuing a diet high in fiber and low in red meat has shown to decrease the incidence of diverticulitis.
A high-fiber diet has long been associated with the prevention of complications of diverticulitis.
Red meat has been noted to be associated with an increased risk of diverticulitis.
Higher levels of C-reactive protein and f2242itin have been associated with consumption of red meat, which might indicate a pathomechanism of diverticulitis predisposition.
A high-fiber diet and physical activity prevents diverticulitis.
The Western diet high in red meat, grains, and high-fat dairy has a hazard ratio of 1.55 to 1.58 compared with a diet high in fruits and vegetables.
Dietary factors such as consumption of red meat, particularly unprocessed red meat, increases risk of diverticulitis,
Increased visceral and subcutaneous fat are independently associated with diverticulitis.
Hospitalization for diverticulitis is more common in white women.
Vegetarian diet and increase physical activity appeared to be protective of diverticular disease.
Current guidelines recommend a high-fiber diet, but no other dietary limitations have been recommended.
Among patients younger than 50 years, diverticulitis occurs more often in men than in women.
The risk of being hospitalized for diverticulitis is three times that associated with diverticular bleeding.
The estimate of 15 to 20% of patients with diverticulosis will develop diverticulitis in their lifetime, is probably an overestimate.
Associated with inflammation of a diverticulum commonly associated with perforation of the bowel either grossly or microscopically.
Current theory suggests that the increased bowel wall pressure is secondary to low-fiber stool, which transmits the force of contraction on the wall rather than on stool content.
The outpouching can become inflamed due to microperforation.
Microperforation in turn, leads to muscle thickening and muscle spasm.
Disease can progress to intra-abdominal abscess, pyelonephritis, perforation, or fistulization to the bladder, a loop of bowel, the skin, or the uterus or vagina.
If untreated diverticulitis may resolve, become chronic, progress with bacterial translocation, and perforation of the colon at the site of inflammation.
When pseudodiverticula, outpouchings of mucosa and submucosa that develop from increased intraluminal pressure, undergo stasis or obstruction with bacterial overgrowth and ischemic changes.
Microbiota may also play a role, as Enterobacteriaceae was found in significantly high levels in patients with diverticular disease.
Depletion of Clostridium cluster IV, Clostridium cluster IX, Fusobacterium, and Lactobacillaceae are found in patients with symptomatic disease.
Greater frequency in the Western world.
Increasingly seen in younger population.
Right sided lesions constitute 0.9-1.7% of cases in the West.
In Asia right sided lesions predominate.
Right sided lesion usually diagnoses with an average age of 40 years.
Asians patients most commonly have diverticulitis on the right side, in the cecum or ascending colon, whereas North American and European patients most commonly have diverticulitis on the left side, in the sigmoid colon and present with this condition at an older age.
Anaerobic organisms most commonly isolated from lesions.
Gram negative organisms commonly cultured from lesions.
Before effective broad-spectrum antibiotics process was a devastating disease with significantly morbidity and mortality.
Acute diverticulitis can present as mild intermittent pain or as chronic severe unrelenting aabdominal pain.
Endoscopic examination is recommended 4 to 6 weeks after a course of diverticulitis to evaluate the colon, given that underlying neoplasia has been reported in 1% to 9.2% of cases.
Frequently associated with change in bowel habits and fever.
Constipation reported in approximately 50% of patients and diarrhea in 25% to 35%.
Patients may present with nausea, vomiting, and urinary tract symptoms.
Approximately 70% of patients with acute diverticulitis present with a gradual onset of left lower quadrant pain.
fever occurs in approximately 1/3 of patients and tachycardia occurs in almost 1/3.
Clinical exam consists of left lower quadrant tenderness, and localized guarding.
Complicated diverticulitis with perforation is a medical emergency and it has abdominal guarding and signs of shock such as tachycardia, and hypotension.
In approximately 20% of patients with complicated diverticulitis, a mass may be palpable in the left lower quadrant associated with the thickened sigmoid colon associated phlegmon or abscess, surrounded by omentum and small intestine
People with right colonic diverticulitis may have suprapubic or right side abdominal pain.
In the case of overt peritonitis the patient may have abdominal rigidity, rebound tenderness, and guarding.
Laboratory evaluation is frequently notable for leukocytosis and elevated inflammatory markers.
Vitamin D levels have shown a correlation, with low levels found in complicated diverticulitis cases and high levels in uncomplicated diverticulitis cases.
Exposure to drugs, including nonsteroidal anti-inflammatory drugs, steroids, and opiates, is associated with diverticulitis, while exposure to statin drugs may decrease the incidence.
Complications include abscess formation, fistula formation, strictures, bowel obstruction and peritonitis.
12 to 15% of patients present with a complicated acute diverticulitis, with 15 to 20% developing an abscess caused by colon perforation.
Most cases resolve with antibiotics.
Routine use of antibiotics may not be necessary in mild cases.
The role of fiber to prevent diverticulitis and its complications is unclear.
Optimal timing and need for surgery is unclear and is no longer considered unnecessary after 2 episodes of diverticulitis.
Surgery to remove the affected part of the colon is sometimes necessary.
The lengthy postoperative hospitalization and morbidity indicates that surgical treatment should be reserved for complicated presentations.
Thus, first noncomplicated episodes should be treated medically.
Not all diverticulitis should be treated with antibiotics: if no fever, the preferred treatment is to manage minor attacks with rest, plenty of liquids, and non-narcotic pain medications
Presently, antibiotics are used only for people who have severe pain, fever, and an elevated white blood cell count, an abscess, or a perforation.
A contained perforation is characterized by an intestinal perforation walled off with omentum and intestines, and sequestered from the rest of the peritoneal cavity.
A free perforation is a perforation accompanied by free flow of colonic contents into the peroneal cavity.
A complicated diverticulitis occurs when uncomplicated diverticulitis progresses, and includes abscess formation, fistula to adjacent organs, or bowel structures, resulting in a large bowel obstruction.
Surgery is recommended after the second or third episode of uncomplicated diverticulitis, with cost savings noted to be most after the third episode of uncomplicated diverticulitis.
Initial non-operative management of complicated diverticulitis with abscess includes antibiotics and or percutaneous drainage of a diverticular abscess: these treatments can cure approximately 80% of patients.
Patients with recurrent uncomplicated episodes of diverticulitis do not have an increased risk of poor outcomes.
Peritonitis may result from rupture of a diverticular associated abscess or from rupture of an uninflamed diverticulum.
1-2% with emergent presentation have a perforation.
Abscess formation may lead to a large and small bowel obstruction in the presence of a large abscess.
Complications may be more serious in immunosuppressed patients such as those who have undergone soldid organ transplantation, have AIDS or who are on corticosteroid medications.
Nuts,corn and seeds are not associated with an increase in diverticulitis or diverticular bleeding (Strate LL)
Earlier recommendations had focused on avoidance of seeds and nuts in the hope of avoiding inflammation of the diverticulum, but the results of a large cohort study showed that eliminating nuts, popcorn, and seeds did not decrease the incidence of diverticulitis.
Previously, expert opinion had suggested that nuts, popcorn, and seeds should be restricted due to possible irritation inciting diverticulitis.
In a large prospective trial, consuming these foods was found not to increase the incidence of diverticulitis, while increased frequency of consuming popcorn has shown to decrease incidence.
Immunosuppressed patients may present with atypical manifestations and are more likely to have suffered perforation.
Immunosuppressed individuals less likely to be managed successfully with conservative treatment and have higher rate of postoperative complications and death than have immunocompetent patients.
Treatment of diverticulitis is based on bowel rest, antibiotics, and pain control as needed.
Antibiotics are aimed at the gastrointestinal flora, including anaerobic gram-negative coverage.
Antibiotic choices include ciprofloxacin with metronidazole, amoxicillin-clavulanate, piperacillin-tazobactam, and meropenem for a duration of 7 to 10 days.
Most patients present with obstipation and left lower quadrant pain with low grade fever, guaiac positive stools and leucocytosis.
This condition can cause a variety of symptoms, including chronic, severe diarrhea, abdominal tenderness, nausea and vomiting, bloating, bleeding from the rectum and fever.
Older patient are less likely to have typical signs and symptoms of diverticulitis.
The differential diagnosis of diverticulitis includes uncomplicated constipation, irritable bowel syndrome, inflammatory, bowel disease, appendicitis, colorectal cancer, kidney stones, UTI, bowel obstruction, and GYN conditions, such as pelvic inflammatory disease, tubo-ovarian torsion, or abscess.
Usually involves sudden, severe pain in the lower left side of the abdomen.
Complications of diverticulitis can include an abscess formation when pus collects in the diverticularb pouches.
Patients with diverticulitis who are on calcium channel blockers, which reduce small muscle contraction, have fewer complications of perforation compared with patients who do not take calcium channel blockers.
Patients with recurrent diverticulitis have similar chemical and histological changes similar to inflammatory bowel disease and irritable bowel syndrome.
Patients with diverticulitis, inflammatory bowel disease and irritable bowel syndrome have higher levels of histamine, tumor necrosis factor-alpha and matrix metalloproteinases.
If an inflamed pouch ruptures, peritonitis occurs.
Perforated colon diverticulitis has an incidence of 3-4/100,000 people per year.
Perforated colon diverticulitis is a highly morbid process and can be lethal.
Severity of perforated colon diverticulitis is proportional to the degree of a abdominal contamination that occurs.
Perforations that result in a contained abscess can be treated with percutaneous drainage procedure and intravenous anabiotics.
CT-guided percutaneous drainage of diverticular abscess is a safe procedure to decrease inflammation prior to surgery.
The recurrence rate of diverticulitis after percutaneous drainage alone is 35.4%, so it is reserved for patients who are poor operative candidates.
Surgery following percutaneous drainage has an associated mortality rate of 7%.
Thus, from single- or double-stage surgery after antibiotics, CT-guided percutaneous drainage before surgery has become the standard in cases of abscesses larger than 3 cm.
Those smaller measuring less than 3 cm are treated medically.
Perforation with uncontained purulent or fecal contamination requires a surgical approach.
Surgical treatment has been found not superior to medical treatment, with nonrecurrence rates of 79% and 75% for surgery and medical treatment, respectively.
The recurrence risk following an acute diverticulitis episode is 13%-23% in patients with uncomplicated diverticulitis and up to 40% in in patients with diverticulitis that is complicated.
Surgery for patients with recurrent diverticulitis showed improved G.I. quality of life index with surgical intervention versus conservative management.
Prolonged diverticulitis can lead to scarring that becomes a blockage in the colon.
Severe cases sometimes cause a fistula, creating an abnormal passageway between different parts of the intestine to the bladder, vagina or abdominal wall.
Fistulae occur in an approximately 5% of patients with acute diverticulitis on an initial presentation and an account for 17 to 27% of surgically treated cases of diverticular disease.
Fistula occur in nearby pelvic organs.
Abdominal mass or rectal fullness may be palpable.
Diagnosis can be confused with appendicitis if the colon is redundant, or if the inflamed part of the intestine is in the suprapubic region of the right lower quadrant.
Must be differentiated from inflammatory bowel disease, pelvic inflammatory disease, tubal pregnancy, colon cancer, cystitis or colitis.
Perforation with peritonitis requires emergent surgical care.
Presently surgeons counsel against an elective collectomy for recurrent uncomplicated diverticulitis and perform urgent resection with diverted anastomosis for complicated disease with peritonitis.
Among patients with likely perforated diverticulitis undergoing emergency surgery the use of laparoscopic surgery versus primary resection did not reduce postoperative complications and lead to worse outcomes and secondary endpoints, suggesting laparoscopic lavage for treatment of perforated diverticulitis is not supported (The SCANDIV Randomized Clinical Trial).
Recent advances in surgical intervention include minimally invasive techniques with primary anastomosis, which have shown to decrease length of stay, pain, and infection rates.
Hinchey’s criteria stages the severity of disease: Stage1-small or confined pericolic or mesenteric abscess, Stage 2-large abscesses often extending into the pelvis, Stage 3-perforated diverticulitis causing purulent peritonitis, Stage 4-free rupture, with rupture of an uninflamed and unobstructed diverticulum into the peritoneal cavity with fecal contamination.
Standard operative approach used to resect the perforated segmented of colon with as much diverticula-diseased colon as possible.
In general the colon is not anastomosed back together and a colostomy is created.
Recently restoring colonic continuity with a primary anastomosis when the peritonitis is not too severe.
Risk of death less than 5% for most patients with stage 1 or 2 disease, approaches 13% for stage 3 disease and 43% for stage 4 disease.
Resection of perforated diverticulitis has a high morbidity rate with 30-50% complications, and a mortality rate of 10 to 20%.
CT of abdomen recommended as the initial imaging diagnostic study.
CT of the abdomen allows for the delineation of the extent of disease.
CT of the abdomen with contrast demonstrates diverticulitis with a sensitivity and a specificity approaching 100%.
The sensitivity of CT of the abdomen/pelvis in acute diverticulitis is 94%, with a specificity of 99%.
Ultrasound has a sensitivity nearing 85% and a specificity of 93-97% in diagnosis.
CT is more expensive but has a lower risk of perforation than barium enema studies and can help diagnose extracolonic pathology.
CT is 97% sensitive,30 making it the standard of care in the diagnosis.
Right sided lesions associated with right flank pain and abdominal tenderness.
Right sided lesions frequently misdiagnosed as appendicitis, cholecystitis, Meckel’s diverticulum and colon cancer.
CT scan findings in right sided diverticular inflammation include inflamed right colon diverticulum, pericolonic fat inflammation or abscess and colon wall thickening.
A contrast enhanced abdominal and pelvic CT scan is the recommended diagnostic test with a sensitivity of 98 to 99% and a specificity of 99 to 100%.
MRI has a sensitivity of 86 to 94% and a specificity of 88 to 92% for acute diverticulitis compared with CT scans.
Colonoscopy, the main diagnostic tool for diagnosing diverticular disease is not used in the setting of acute diverticulitis because of the danger of perforation.
Diverticulitis can be identified on colonoscopy and is seen in 2% of screening colonoscopies.
Colonoscopy cannot identify complications of diverticulitis such as abscess.
Contrast enema should not be used to evaluate patients with possible acute diverticulitis, because it may cause colonic perforation.
Hinchey’s classification grades that classify left-sided lesions may be extrapolated to right-sided lesions.
Early right-sided lesions can be managed expectantly with antibiotics, but surgery will be needed for those that deteriorate with non surgical approach.
Presently elective colectomy is reserved for recurrent uncomplicated diverticulitis and often performed as urgent resection with diverted anastomosis for complicated disease with peritonitis.
Elective colectomy is considered 4 to 6 weeks after successful non-operative management of diverticular abscess due to the risk of complicated recurrences, such as stricture, bowel obstruction, or fistula formation.
Elective colectomy rates for diverticulitis is about 3.1 per hundred thousand and emergency colectomy rates is about 1.5 per hundred thousand.
The emergency colectomy mortality rate is about 10% and electivecolectomy is associated with about a 0.5% mortality rate.
Approximately 4% of patients require a stoma following elective colonic resection.
Patients who did not improve or worsen with antibiotics and pain management and those with diffuse feculent peritonitis with septic shock should undergo urgent or emergency surgery.
Surgical management of diverticular disease consist of removing the disease segment of the colon and repairing the resultant discontinuous colon either by creating an end colostomy (Hartmann procedure) or a primary anastomosis.
Currently, a conservative medical route utilizing antibiotics selectively is recommended in cases of uncomplicated diverticulitis.
Approximately 85% of people with acute diverticulitis, have an uncomplicated process with the absence of abscess, stricture, perforation, or fistula formation.
management:
Management of uncomplicated diverticulitis consists of observation and pain management and dietary modification with a clear liquid diet.
Acetaminophen is the preferred treatment for pain in the outpatient setting and non-steroidal anti-inflammatory drugs should be avoided because they may increase the risk of diverticular bleeding.
Several studies even question the need for antibiotics; antibiotics are reserved for patients with systemic symptoms, such as persistent, fever, chills, those older than 80 years, and those who are pregnant, those who are immunocompromised, those on high dose steroids, and those with chronic medical conditions, such as cirrhosis, kidney disease, heart failure, or poorly controlled diabetes.
Randomized clinical trials conclude the antibiotics for uncomplicated acute diverticulitis is not superior to management without antibiotics.
For patients with uncomplicated acute diverticulitis who require antibiotics, broad spectrum antibiotics against gram-negative bacilli and anaerobic bacteria should be administered for 4 to 7 days: amoxicillin/clavulanate acid, oral cephalosporin, such as cephalexin plus metronidazole.
Recurrence is a relative indication for surgical intervention, and percutaneous drainage is offered for cases with an abscess greater than 3 cm.
Once diverticulitis has been diagnosed, judicious use of antibiotics is recommended in uncomplicated episodes.
In recent studies, antibiotic treatment was found to be of no benefit in cases of uncomplicated diverticulitis, while current recommendations call for antibiotics to be used selectively, without clear indications identified.
Intravenous antibiotics such as ceftiaxone plus metronidazole are first line therapies for patients requiring hospitalization for diverticulitis.
No significant difference has been found between oral and intravenous antibiotics, nor between anaerobic coverage and no anaerobic coverage.
Similarly, no statistically significant differences have been found between inpatient and outpatient antibiotic treatment in uncomplicated and mildly complicated diverticulitis.
A failure rate of 6.2% for oral antibiotics warrants outpatient treatment of uncomplicated diverticulitis whenever possible.
Studies are under way to determine the need for antibiotics by treating uncomplicated cases without antibiotics.
In complicated diverticulitis, control of the source of infection and adequate initial empirical antibiotic therapy are important to improve clinical outcomes.
Complicated and recurrent episodes can be treated surgically, with the greatest benefit after the third episode.
Colonoscopy is recommended 4 to 6 weeks after the episode to exclude underlying neoplasia.