diverticulosis & diverticulitis victor politi, m.d., facp medical director, svcmc school of...

Diverticulosis & Diverticulosis & DiverticulitisDiverticulitis

Victor Politi, M.D., FACPVictor Politi, M.D., FACP

Medical Director, SVCMC School of Medical Director, SVCMC School of Allied Health Physician Assistant Allied Health Physician Assistant ProgramProgram

Diverticulum – A diverticulum is a pouch or Diverticulum – A diverticulum is a pouch or a pocket-like opening in the bowel wall, a pocket-like opening in the bowel wall, usually in the colon. usually in the colon. The pouch is formed by the hernia of superficial The pouch is formed by the hernia of superficial

layers of the colon through the weak points in layers of the colon through the weak points in the bowel wall a small pouch in the colon that the bowel wall a small pouch in the colon that bulges outward through a weak spot bulges outward through a weak spot

The occurrence of a diverticulum is known The occurrence of a diverticulum is known as diverticulosisas diverticulosis

About 10 percent of Americans over About 10 percent of Americans over the age of 40 have diverticulosis. the age of 40 have diverticulosis.

The condition becomes more common The condition becomes more common as people age. as people age.

About half of all people over the age About half of all people over the age of 60 have diverticulosis. of 60 have diverticulosis.

Normal Abnormal

When the pouches become infected or When the pouches become infected or inflamed, the condition is called inflamed, the condition is called diverticulitis. diverticulitis.

This happens in 10 to 25 percent of This happens in 10 to 25 percent of people with diverticulosis. people with diverticulosis.

Diverticulosis and diverticulitis are Diverticulosis and diverticulitis are also called also called diverticular diseasediverticular disease

Diverticulitis can occur anywhere in Diverticulitis can occur anywhere in the gastrointestinal tract the gastrointestinal tract most commonly observed in the colon. most commonly observed in the colon. Small bowel diverticulitis is far less Small bowel diverticulitis is far less

common than colonic diverticulitis. common than colonic diverticulitis. Asymptomatic diverticulosis is a Asymptomatic diverticulosis is a

common condition, but few patients common condition, but few patients with diverticula develop with diverticula develop symptomatic diverticulitis. symptomatic diverticulitis.

Diverticulitis -generally considered a Diverticulitis -generally considered a disease of the elderly population butdisease of the elderly population but as many as 20% of patients with as many as 20% of patients with

diverticulitis are younger than 50 years. diverticulitis are younger than 50 years. Diverticulitis may be a more severe Diverticulitis may be a more severe

illness when observed in younger illness when observed in younger patientspatients

painful diverticular painful diverticular diseasedisease

The diverticula are usually harmless The diverticula are usually harmless and do not cause problems in 70-and do not cause problems in 70-80% of patients80% of patients

Some persons may develop cramps, Some persons may develop cramps, bloating, and irregular bowel bloating, and irregular bowel movements without fever or other movements without fever or other signs of infection. signs of infection.

These patients are believed to have These patients are believed to have "painful diverticular disease” "painful diverticular disease”

A cause-effect relationship between A cause-effect relationship between these symptoms and diverticulosis these symptoms and diverticulosis has not been established.has not been established. patients usually treated with high fiber patients usually treated with high fiber

diet plus medications to relieve spasms diet plus medications to relieve spasms Some of these patients may not Some of these patients may not

respond to medical therapy. respond to medical therapy. Use of surgery in such patients in the Use of surgery in such patients in the

absence of giant diverticula and or any absence of giant diverticula and or any of its complications is controversial of its complications is controversial

painful diverticular painful diverticular diseasedisease

In about 25% of patients with painful In about 25% of patients with painful diverticular disease - develops in the diverticular disease - develops in the bowel wall through the diverticulum bowel wall through the diverticulum leading to infection and inflammation leading to infection and inflammation around the colon. around the colon.

This complication is known as This complication is known as diverticulitis. diverticulitis.

The infection usually stays localized, but The infection usually stays localized, but can spread into the abdomen causing can spread into the abdomen causing severe diverticulitis. severe diverticulitis.

Senior citizens are prone to the more serious Senior citizens are prone to the more serious form, especially if they are taking medications form, especially if they are taking medications that increase susceptibility to infection. that increase susceptibility to infection.

Patients develop pain in the lower, left part of Patients develop pain in the lower, left part of the abdomen, along with fever and other signs the abdomen, along with fever and other signs of infection. of infection.

A majority of patients report nausea, A majority of patients report nausea, vomiting, distended abdomen or recent vomiting, distended abdomen or recent "constipation". "constipation".

Acute inflammation in the colon may also Acute inflammation in the colon may also affect adjacent organs like the bladder, affect adjacent organs like the bladder, causing painful or increased urination causing painful or increased urination

Diverticulitis occurs when diverticula Diverticulitis occurs when diverticula become infected or inflamed. become infected or inflamed.

It is unclear as to what causes the It is unclear as to what causes the infection. infection. It may begin when stool or bacteria are It may begin when stool or bacteria are

caught in the diverticula. caught in the diverticula. An attack of diverticulitis can develop An attack of diverticulitis can develop

suddenly and without warning suddenly and without warning

What causes diverticular What causes diverticular disease?disease?

What causes diverticular disease?What causes diverticular disease?

The etiology of diverticulitis remains unclear, The etiology of diverticulitis remains unclear,

A low-fiber diet is considered a predisposing A low-fiber diet is considered a predisposing factorfactor

Diverticular disease is common in developed or Diverticular disease is common in developed or industrialized countries--particularly the United industrialized countries--particularly the United States, England, and Australia--where low-fiber States, England, and Australia--where low-fiber diets are common. diets are common.

The disease is rare in countries of Asia and Africa, The disease is rare in countries of Asia and Africa, where people eat high-fiber vegetable diets.where people eat high-fiber vegetable diets.

Fiber is the part of fruits, Fiber is the part of fruits, vegetables, and grains that the body vegetables, and grains that the body cannot digest. cannot digest. Some fiber dissolves easily in water Some fiber dissolves easily in water

(soluble fiber). It takes on a soft, jelly-(soluble fiber). It takes on a soft, jelly-like texture in the intestines. like texture in the intestines.

Some fiber passes almost unchanged Some fiber passes almost unchanged through the intestines (insoluble fiber). through the intestines (insoluble fiber).

The low-fiber diet connectionThe low-fiber diet connection

Both kinds of fiber help make stools soft Both kinds of fiber help make stools soft and easy to pass. Fiber also prevents and easy to pass. Fiber also prevents constipationconstipation

Constipation makes the muscles strain Constipation makes the muscles strain to move stool that is too hard. to move stool that is too hard. It is the main cause of increased pressure It is the main cause of increased pressure

in the colon. in the colon. This excess pressure might cause the weak This excess pressure might cause the weak

spots in the colon to bulge out and become spots in the colon to bulge out and become diverticula diverticula

The low-fiber diet connectionThe low-fiber diet connection

Aging Aging causes changes in collagen structure- may causes changes in collagen structure- may

lead to weakening of the colonic wall.lead to weakening of the colonic wall. Colonic motility disordersColonic motility disorders Long term Corticosteroid or NSAID use Long term Corticosteroid or NSAID use Genetics Genetics

believed to play a role, Asian people tend to believed to play a role, Asian people tend to have a predominance of right-sided have a predominance of right-sided diverticula, while Western people tend to diverticula, while Western people tend to have left-sided diseasehave left-sided disease

Other Possible Predisposing Other Possible Predisposing FactorsFactors

Diverticulosis SymptomsDiverticulosis Symptoms Most people with diverticulosis do not Most people with diverticulosis do not

have any discomfort or symptoms. have any discomfort or symptoms. However, symptoms may include mild However, symptoms may include mild

cramps, bloating, and constipation. cramps, bloating, and constipation. Other diseases such as irritable bowel Other diseases such as irritable bowel

syndrome (IBS) and stomach ulcers cause syndrome (IBS) and stomach ulcers cause similar problems, so these symptoms do not similar problems, so these symptoms do not always mean a person has diverticulosis. always mean a person has diverticulosis.

DiverticulitisDiverticulitisSymptomsSymptoms

Most common symptom -abdominal painMost common symptom -abdominal pain Most common sign- tenderness around the Most common sign- tenderness around the

left side of the lower abdomenleft side of the lower abdomen

If infection is the cause, fever, nausea, If infection is the cause, fever, nausea, vomiting, chills, cramping, and constipation vomiting, chills, cramping, and constipation may occur as well. may occur as well.

The severity of symptoms depends on the The severity of symptoms depends on the extent of the infection and complications extent of the infection and complications

Diverticulitis Diverticulitis ComplicationsComplications

Diverticulitis can lead to Diverticulitis can lead to AbscessAbscess Diverticular Hemorrhage Diverticular Hemorrhage Intestinal fistulaIntestinal fistula Intestinal perforationIntestinal perforation Intestinal obstructionIntestinal obstruction Sepsis and septic shockSepsis and septic shock


Diverticular Hemorrhage Diverticular Hemorrhage rare complication 5% of cases rare complication 5% of cases sudden in onset, painless and substantial -sudden in onset, painless and substantial -

the result of a weakened blood vessel in a the result of a weakened blood vessel in a diverticulum burstingdiverticulum bursting

Bleeding is usually not seen during an acute Bleeding is usually not seen during an acute episode of acute diverticulitis - Diverticula episode of acute diverticulitis - Diverticula bleed when they are otherwise healthy bleed when they are otherwise healthy

bleeding stops spontaneously in most bleeding stops spontaneously in most patients. patients.

Diverticular HemorrhageDiverticular Hemorrhage In some cases, the bleeding may In some cases, the bleeding may

continue intermittently for a few hours continue intermittently for a few hours to a few days before resolvingto a few days before resolving

Chronic intermittent bleeding due to Chronic intermittent bleeding due to diverticulosis is unusual diverticulosis is unusual

As many as 80% patients do not have As many as 80% patients do not have any recurrence of bleeding. any recurrence of bleeding.

Surgery may be needed in 50% of cases Surgery may be needed in 50% of cases of massive diverticular bleeding. of massive diverticular bleeding.


Infection Infection Treated with antibiotics Treated with antibiotics usually clears up after a few days of usually clears up after a few days of

treatment treatment Rest the Gut Rest the Gut

Abscess - Abscess - An abscess is an infected area with pus An abscess is an infected area with pus

that may cause swelling and destroy that may cause swelling and destroy tissue tissue


Perforation-Perforation- Sometimes the infected diverticula may develop Sometimes the infected diverticula may develop

small holes (perforations) small holes (perforations) The perforations allow pus to leak out of the The perforations allow pus to leak out of the

colon into the abdominal area colon into the abdominal area If the abscess is small and remains in the colon, If the abscess is small and remains in the colon,

it may clear up after treatment with antibiotics. it may clear up after treatment with antibiotics. If the abscess does not clear up with antibiotics, If the abscess does not clear up with antibiotics,

it may require drainage (percutaneous catheter it may require drainage (percutaneous catheter drainage) drainage)

Sometimes surgery is needed to clean the Sometimes surgery is needed to clean the abscess and, if necessary, remove part of the abscess and, if necessary, remove part of the coloncolon


Peritonitis- Peritonitis- (an infection of the abdominal (an infection of the abdominal cavity) cavity) A large abscess can become a serious A large abscess can become a serious

problem if the infection leaks out and problem if the infection leaks out and contaminates areas outside the colon. contaminates areas outside the colon.

Infection that spreads into the abdominal Infection that spreads into the abdominal cavity is called peritonitis. cavity is called peritonitis.

Peritonitis requires immediate surgery to Peritonitis requires immediate surgery to clean the abdominal cavity and remove clean the abdominal cavity and remove the damaged part of the colon. the damaged part of the colon.

Without surgery, peritonitis can be fatal.Without surgery, peritonitis can be fatal.


Fistula- Fistula- Abnormal connection of tissue between two Abnormal connection of tissue between two

organs or between an organ and the skinorgans or between an organ and the skin When damaged tissues come into contact with When damaged tissues come into contact with

each other during infection, they sometimes stick each other during infection, they sometimes stick together. If they heal that way, a fistula formstogether. If they heal that way, a fistula forms

When diverticulitis-related infection spreads When diverticulitis-related infection spreads outside the colon, the colon's tissue may outside the colon, the colon's tissue may stick to nearby tissues. stick to nearby tissues. The organs usually involved are the bladder, The organs usually involved are the bladder,

small intestine, and skin.small intestine, and skin.


FistulaFistula The most common type of fistula occurs The most common type of fistula occurs

between the bladder and the colon. between the bladder and the colon. Colovesicular fistula (colon to urinary Colovesicular fistula (colon to urinary bladder). bladder).

This is observed almost exclusively in menThis is observed almost exclusively in men Also seen in women following hysterectomy Also seen in women following hysterectomy This type of fistula can result in a severe, long-This type of fistula can result in a severe, long-

lasting infection of the urinary tract. lasting infection of the urinary tract. Can be corrected with surgery to remove the fistula Can be corrected with surgery to remove the fistula

and the affected part of the colon and the affected part of the colon Colovaginal and colocutaneous fistulae are Colovaginal and colocutaneous fistulae are

much less common much less common


Intestinal Obstruction Intestinal Obstruction The scarring caused by infection may The scarring caused by infection may

cause partial or total blockage of the cause partial or total blockage of the large intestine. large intestine.

When this happens, the colon is unable When this happens, the colon is unable to move bowel contents normally. to move bowel contents normally.

If the obstruction totally blocks the If the obstruction totally blocks the intestine, emergency surgery is intestine, emergency surgery is necessarynecessary


The diagnosis of acute diverticulitis The diagnosis of acute diverticulitis is often made on the basis of history is often made on the basis of history and physical examination, followed and physical examination, followed by confirmatory laboratory and by confirmatory laboratory and radiologic tests radiologic tests

diagnosing diverticular diagnosing diverticular diseasedisease

medical historymedical history bowel habits, symptoms, pain, diet, medications bowel habits, symptoms, pain, diet, medications

physical examphysical exam digital rectal exam, occult blood, bloodwork, digital rectal exam, occult blood, bloodwork,

diagnostic testsdiagnostic tests Imaging studies, endoscopyImaging studies, endoscopy

Most people do not have symptoms so Most people do not have symptoms so diverticulosis is often found through tests diverticulosis is often found through tests ordered for another ailmentordered for another ailment

History/PhysicalHistory/Physical The clinical presentation of The clinical presentation of

diverticulitis depends on: diverticulitis depends on: locationlocation severity of the underlying severity of the underlying

inflammatory processinflammatory process and on whether complications are and on whether complications are

present present

Frequent Symptoms of acute diverticulitis - Frequent Symptoms of acute diverticulitis - abdominal pain and fever abdominal pain and fever Usually, pain is severe, abrupt in onset, localized Usually, pain is severe, abrupt in onset, localized

to the left lower abdominal quadrant, and to the left lower abdominal quadrant, and worsens steadily over time.worsens steadily over time.

Sometimes referred to as left-sided appendicitis, Sometimes referred to as left-sided appendicitis, diverticulitis is often accompanied by anorexia, diverticulitis is often accompanied by anorexia, nausea, and vomiting.nausea, and vomiting.

Altered bowel habit, especially constipation, Altered bowel habit, especially constipation, is commonis common

History/PhysicalHistory/Physical

Because diverticula and diverticulitis Because diverticula and diverticulitis can develop anywhere in the can develop anywhere in the gastrointestinal tract, symptoms may gastrointestinal tract, symptoms may mimic multiple conditions.mimic multiple conditions.


Diverticulitis in the transverse colon may mimic Diverticulitis in the transverse colon may mimic peptic ulcer disease, pancreatitis, or peptic ulcer disease, pancreatitis, or cholecystitis.cholecystitis.

Diverticulitis in the right colon may be Diverticulitis in the right colon may be confused with acute appendicitis.confused with acute appendicitis.

With disease progression, localized abscess With disease progression, localized abscess and phlegmonous formation may occur. and phlegmonous formation may occur.

Systemic signs of infection, such as fever Systemic signs of infection, such as fever and leukocytosis, become more and leukocytosis, become more pronounced.pronounced.


Localized peritonitis may lead to direct and Localized peritonitis may lead to direct and rebound tenderness over the involved area. rebound tenderness over the involved area.

On physical examination, rebound tenderness On physical examination, rebound tenderness is generally most pronounced in the left is generally most pronounced in the left lower abdominal quadrant. lower abdominal quadrant.

The abdomen may become distended and The abdomen may become distended and tympanic to percussion. tympanic to percussion.

Bowel sounds may become diminished or Bowel sounds may become diminished or absent. absent.

Sometimes, a mass may be felt at the site of Sometimes, a mass may be felt at the site of the inflammation. the inflammation. This may be apparent not only on abdominal This may be apparent not only on abdominal

palpation but also on pelvic or rectal examination palpation but also on pelvic or rectal examination


Elderly patients and those taking Elderly patients and those taking corticosteroids may have corticosteroids may have unremarkable findings on physical unremarkable findings on physical examination, even in the presence of examination, even in the presence of severe diverticulitis. severe diverticulitis. Such patients must be approached with Such patients must be approached with

a high index of suspicion, in order to a high index of suspicion, in order to avoid a significant delay in arriving at avoid a significant delay in arriving at the correct diagnosis.the correct diagnosis.


Hematochezia, or bright red blood per Hematochezia, or bright red blood per rectum, is not a symptom of rectum, is not a symptom of diverticulitis, although occult blood in diverticulitis, although occult blood in the stool is present in approximately the stool is present in approximately 25% of patients with diverticulitis. 25% of patients with diverticulitis. When hematochezia is noted, other causes When hematochezia is noted, other causes

(eg, hemorrhoids, neoplastic disease, (eg, hemorrhoids, neoplastic disease, colitis, vascular ectasias, arterial bleeding colitis, vascular ectasias, arterial bleeding from diverticulosis) should be consideredfrom diverticulosis) should be considered


If a colovesicular fistula is present, If a colovesicular fistula is present, urinary tract symptoms, including urinary tract symptoms, including dysuria, urgency, pneumaturia, dysuria, urgency, pneumaturia, fecaluria, and recurrent urinary fecaluria, and recurrent urinary tract infections, may be prominent. tract infections, may be prominent.

Patients with colovaginal fistulas Patients with colovaginal fistulas may present with a purulent vaginal may present with a purulent vaginal discharge.discharge.


Colovesical Fistula

Leg pain, possibly associated with Leg pain, possibly associated with thigh abscess, and leg emphysema thigh abscess, and leg emphysema secondary to retroperitoneal secondary to retroperitoneal perforation from diverticulitis have perforation from diverticulitis have been reported.been reported.


Lab StudiesLab Studies

Routine laboratory data are Routine laboratory data are important to confirm the presence of important to confirm the presence of infection and to exclude other infection and to exclude other possible etiologies of abdominal possible etiologies of abdominal pain.pain.

Lab StudiesLab Studies CBC -identifies leukocytosis and/or a left shift. CBC -identifies leukocytosis and/or a left shift.

However, 20-40% of patients may have a white However, 20-40% of patients may have a white blood cell count in the reference range, blood cell count in the reference range, particularly patients who are particularly patients who are immunocompromised and elderly.immunocompromised and elderly.

ChemistriesChemistries Liver function tests and amylase/lipase may help Liver function tests and amylase/lipase may help

exclude other causes of abdominal pain, especially exclude other causes of abdominal pain, especially in atypical presentations or generalized in atypical presentations or generalized peritonitis.peritonitis.

Serum electrolyte findings can help detect Serum electrolyte findings can help detect important abnormalities in cases of sepsis or GI important abnormalities in cases of sepsis or GI bleeding.bleeding.

Lab StudiesLab Studies

Blood cultures should be obtained Blood cultures should be obtained prior to administration of empiric prior to administration of empiric antimicrobial therapy.antimicrobial therapy.

Urinalysis and urine cultures Urinalysis and urine cultures to identify urinary tract infectionto identify urinary tract infection In the presence of a colovesicular In the presence of a colovesicular

fistula-fistula- urinary cultures may reveal a polymicrobial urinary cultures may reveal a polymicrobial

infectioninfection

Imaging StudiesImaging Studies X-rays to make sure the colon has not X-rays to make sure the colon has not

perforatedperforated CT scan with contrast of the CT scan with contrast of the

abdomen/pelvis if the diagnosis is abdomen/pelvis if the diagnosis is unclearunclear

Flexible Sigmoidoscopy and Barium Flexible Sigmoidoscopy and Barium enema only after symptoms are enema only after symptoms are improved (if these tests are done too improved (if these tests are done too early, they can cause a colon early, they can cause a colon perforation)perforation)

Imaging StudiesImaging Studies

On plain radiograph, an abdominal On plain radiograph, an abdominal series with flat and upright series with flat and upright abdominal films may show an abdominal films may show an obstruction, ileus, or free air, obstruction, ileus, or free air, indicating visceral perforation. indicating visceral perforation. Radiopaque gallbladder or renal Radiopaque gallbladder or renal stones may also be observed stones may also be observed

CT scan of the abdomen is CT scan of the abdomen is considered the optimal method of considered the optimal method of investigation in patients suspected investigation in patients suspected of acute diverticulitis. of acute diverticulitis.

CT scan is also very helpful in CT scan is also very helpful in determining the extent of determining the extent of complications of the disease complications of the disease

Imaging StudiesImaging Studies

ProceduresProcedures

Endoscopy is not usually used in the Endoscopy is not usually used in the evaluation of acute episodes of evaluation of acute episodes of diverticulitis because of the diverticulitis because of the possibility of perforation and possibility of perforation and subsequent development of subsequent development of peritonitis peritonitis

Treatment of Treatment of diverticulitisdiverticulitis

Treatment for diverticulitis focuses on:Treatment for diverticulitis focuses on: clearing up the infection and inflammationclearing up the infection and inflammation resting the colon resting the colon (bed rest,liquid diet, pain (bed rest,liquid diet, pain

meds as needed)meds as needed) preventing or minimizing complications preventing or minimizing complications

An attack of diverticulitis without An attack of diverticulitis without complications may respond to antibiotics complications may respond to antibiotics within a few days if treated early.within a few days if treated early.


Dependent on:Dependent on: clinical presentationclinical presentation the location of the lesionthe location of the lesion severity of underlying inflammatory severity of underlying inflammatory

processprocess comorbid factors. comorbid factors.

In mild cases, the diagnosis of In mild cases, the diagnosis of diverticulitis can be made with diverticulitis can be made with confidence on the basis of clinical confidence on the basis of clinical examination findings. examination findings. These patients are not very ill and are These patients are not very ill and are

able to tolerate food and oral fluids. able to tolerate food and oral fluids. Patients with mild diverticulitis can be Patients with mild diverticulitis can be

started on an outpatient treatment started on an outpatient treatment regimen. regimen.


Outpatient treatment consists of Outpatient treatment consists of a liquid diet a liquid diet 7-10 days of oral broad-spectrum 7-10 days of oral broad-spectrum

antimicrobial therapyantimicrobial therapy which covers anaerobic microorganisms such as which covers anaerobic microorganisms such as

Bacteroides fragilisBacteroides fragilis and and PeptostreptococcusPeptostreptococcus and and ClostridiumClostridium organisms, as well as aerobic organisms, as well as aerobic microorganisms such as microorganisms such as Escherichia coliEscherichia coli and and Klebsiella, Proteus, Streptococcus,Klebsiella, Proteus, Streptococcus, and and EnterobacterEnterobacter organisms. organisms.

One typical antibiotic regimen is a One typical antibiotic regimen is a combination of ciprofloxacin and combination of ciprofloxacin and metronidazolemetronidazole


Hospitalization is required if:Hospitalization is required if: patients are unable to tolerate oral patients are unable to tolerate oral

hydrationhydration if outpatient therapy failsif outpatient therapy fails if notable fever and/or peritoneal signs if notable fever and/or peritoneal signs

developdevelop if pain is severe enough to require if pain is severe enough to require

narcotic analgesianarcotic analgesia or if patients have a chronic underlying or if patients have a chronic underlying

medical condition. medical condition.


These patients have moderate-to-severe These patients have moderate-to-severe diverticulitis; diverticulitis; do not provide anything by mouth. do not provide anything by mouth.

Initiate intravenous fluid hydration and Initiate intravenous fluid hydration and start broad-spectrum intravenous start broad-spectrum intravenous antibiotic coverage. antibiotic coverage. The typical standard triple antibiotic The typical standard triple antibiotic

regimen in these situations is a regimen in these situations is a combination of ampicillin, gentamicin, and combination of ampicillin, gentamicin, and metronidazole.metronidazole.


Pain management is also important. Pain management is also important. Meperidine is an appropriate choice if Meperidine is an appropriate choice if

narcotics are required. Avoid morphine narcotics are required. Avoid morphine sulfate because it can cause colonic spasm.sulfate because it can cause colonic spasm.

Once the acute episode has resolved, Once the acute episode has resolved, instruct the patient to maintain a high-instruct the patient to maintain a high-fiber diet and to undergo elective fiber diet and to undergo elective colonoscopy colonoscopy


Surgical treatment is usually Surgical treatment is usually necessary in only 20-30% of patients necessary in only 20-30% of patients with acute diverticulitis with acute diverticulitis


When is surgery necessary?When is surgery necessary? If attacks are severe or frequent If attacks are severe or frequent complications of a fistula or intestinal complications of a fistula or intestinal

obstruction obstruction emergency surgery may be required for emergency surgery may be required for

-a large abscess, perforation, -a large abscess, perforation, peritonitis, or continued bleedingperitonitis, or continued bleeding


Emergency surgery usually involves two Emergency surgery usually involves two operations. operations. The first clears the infected abdominal The first clears the infected abdominal

cavity/removes part of the colon cavity/removes part of the colon The second rejoins the ends of the colonThe second rejoins the ends of the colon

Due to infection/obstruction, it is not safe to Due to infection/obstruction, it is not safe to rejoin the colon during the first operation. rejoin the colon during the first operation. Instead, a temporary hole, or stoma, in the abdomen Instead, a temporary hole, or stoma, in the abdomen

is made is made The end of the colon is connected to the hole, a The end of the colon is connected to the hole, a

procedure called a colostomy, to allow normal procedure called a colostomy, to allow normal eating and bowel movements. eating and bowel movements.


In the elective setting, patient evaluation In the elective setting, patient evaluation should be conducted after the resolution of should be conducted after the resolution of an episode of acute diverticulitis. an episode of acute diverticulitis.

The colon requires full evaluation with The colon requires full evaluation with colonoscopy or barium enema to establish colonoscopy or barium enema to establish the extent of disease and to rule out lesions the extent of disease and to rule out lesions such as polyps or carcinoma.such as polyps or carcinoma.

Diverticulitis may lead to stricture formation Diverticulitis may lead to stricture formation that can have the appearance of carcinoma; that can have the appearance of carcinoma; a biopsy of such a lesion should be a biopsy of such a lesion should be performedperformed

Further Outpatient Further Outpatient ManagementManagement

Administer nothing by mouth in Administer nothing by mouth in episodes of moderate-to-severe episodes of moderate-to-severe acute diverticulitis.acute diverticulitis.

In mild episodes, a clear liquid diet In mild episodes, a clear liquid diet is advised.is advised.

Long-term management includes a Long-term management includes a high-fiber, low-fat, and low-beef diet.high-fiber, low-fat, and low-beef diet.

Dietary ManagementDietary Management

Increasing the amount of fiber in the Increasing the amount of fiber in the diet may reduce symptoms of diet may reduce symptoms of diverticulosis and prevent diverticulosis and prevent complications such as diverticulitis. complications such as diverticulitis. Fiber keeps stool soft and lowers Fiber keeps stool soft and lowers

pressure inside the colon so that bowel pressure inside the colon so that bowel contents can move through easily. contents can move through easily.

The American Dietetic Association The American Dietetic Association recommends 20 to 35 grams of fiber recommends 20 to 35 grams of fiber each day. each day.


Fiber product –Fiber product – Citrucel or Metamucil once a day. Citrucel or Metamucil once a day.

These products are mixed with water These products are mixed with water and provide about 2 to 3.5 grams of and provide about 2 to 3.5 grams of fiber per tablespoon, mixed with 8 fiber per tablespoon, mixed with 8 ounces of water. ounces of water.


Diverticulosis is a very common, and Diverticulosis is a very common, and usually a very benign conditionusually a very benign condition

Complications occur only in a Complications occur only in a minority of patients, and most of minority of patients, and most of them get well with medical them get well with medical treatment alone without any need treatment alone without any need for surgery for surgery

diverticulosis & diverticulitis victor politi, m.d., facp medical director, svcmc school of...

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