Diverticular disease is when problems occur due to diverticulosis, a benign condition defined by the formation of pouches (diverticula) from weak spots in the wall of the large intestine.[1] This disease spectrum includes diverticulitis, symptomatic uncomplicated diverticular disease (SUDD), and segmental colitis associated with diverticulosis (SCAD).[2] The most common symptoms across the disease spectrum are abdominal pain and bowel habit changes such as diarrhea or constipation. Otherwise, diverticulitis presents with systemic symptoms such as fever and elevated white blood cell count whereas SUDD and SCAD do not. Treatment ranges from conservative bowel rest to medications such as antibiotics, antispasmodics, acetaminophen, mesalamine, rifaximin, and corticosteroids depending on the specific conditions.
| Diverticular disease | |
|---|---|
 | |
| Endoscopic image of diverticulosis (showing two diverticula) | |
| Specialty | Gastroenterology |
| Symptoms | Abdominal pain, bowel habit changes, nausea, vomiting |
| Causes | Diverticulosis |
| Diagnostic method | Abdominal imaging, white blood cell count, inflammatory markers, fecal calprotectin, colonoscopy and biopsy |
| Differential diagnosis | Crohn's disease, ulcerative colitis, irritable bowel syndrome, colorectal cancer |
| Treatment | Antibiotics, antispasmodics, mesalamine, rifaximin, corticosteroids |
Signs and symptoms
editThe signs and symptoms of diverticular disease stem from inflammation and irritation of the colonic tissues, which can manifest as:
- Abdominal pain that may be persistent for days. Pain is typically located in the left lower quadrant. However, in people of Asian descent, pain is reported more on the right side.[3]
- Diarrhea
- Constipation
- Nausea and vomiting
- Fever
- Rectal bleeding
Causes
editDiverticulitis
editAcute diverticulitis is thought to arise from either trauma or lack of blood flow to the existing diverticulum in the colon.
- The traumatic theory proposes that a fecalith, which is a hardened fecal matter, becomes trapped in a diverticulum, leading to colonic mucosa abrasion and local inflammation. Subsequent bacterial overgrowth and infection spreads from the mucosal wall to full bowel wall, eventually leading to bowel perforation.[2]
- In the ischemic theory, it is thought that long standing colonic contraction causes blood vessel compression at the diverticular neck, leading to ischemia, inflammatory response, and perforation.[2] These long standing contractions are attributed to lower choline acetyltransferase activity in the colonic circular muscle layer.[4]
Complicated acute diverticulitis is distinguished from uncomplicated diverticulitis by the presence of abscess or colonic perforation.
Chronic smoldering diverticulitis is caused by recurrent acute diverticulitis that does not respond to medical treatment but does not progress to complications such as abscess, peritonitis, enteric fistula, or bowel obstruction.[5]
Symptomatic uncomplicated diverticular disease
editSimilar to the diverticulitis ischemia theory above, SUDD is thought to be caused by sustained colonic contraction leading to mucosal ischemia within the diverticulum.[2] However, SUDD occurs when only abdominal pain with bowel habit change is present, without any other systemic symptoms of diverticulitis like fever, elevated white blood cell count, elevated C-reactive protein.[6]
Low grade inflammation of the colonic mucosa within the diverticulum and visceral hypersensitivity are also thought to cause SUDD.[6]
Segmental colitis associated with diverticulosis
editSCAD, also known as diverticular colitis, is when there is mucosal inflammation in a colonic segment with diverticulosis that may or may not have evidence of diverticulitis, or inflammation within or around a diverticulum itself. The involved colonic segment is mostly confined to the sigmoid. The cause is currently unknown. It is thought to be multi-factorial, including colonic ischemia secondary to old age and other cardiovascular risk factors, diverticulosis causing mucosal prolapse, fecal stasis and subsequent microbiome disturbance, eventually leading to inflammation of the colon segment.[7]
Risk Factors
editMany risk factors contribute to the development and severity of diverticular disease, such as
- Advanced age – diverticular disease typically presents in the sixth decade of life.[8]
- Colonic wall structure – points of blood vessel entry in the colonic wall are weaker and more prone to mucosal herniation.
- Fiber intake – although it is widely believed that low fiber diet is associated with diverticulosis and diverticular disease, recent studies have not confirmed the association but has shown that increased fiber intake reduces diverticular disease complications.[9]
- NSAIDs and Aspirin use – these drugs have been shown to increase risk of diverticular bleeding and diverticulitis complications such as diverticular perforation.[10]
- Genetics – over 30 susceptibility loci have been identified for diverticular disease,[11] including ARHGAP15, COLQ, and FAM155A.[12]
- Vitamin D – although the mechanism is unclear, recent studies have shown that vitamin D insufficient patients have higher risk of complicated diverticulitis.[9]
Diagnosis
editDiverticulitis
editDiverticulitis typically presents with tenderness in the left lower abdomen, fever, bowel habit changes such as constipation or diarrhea. Laboratory abnormalities include elevated white blood count and inflammatory markers (C-reactive protein and erythrocyte sedimentation rate). Imaging via computed tomography (CT) is the standard for diagnosing diverticulitis and evaluating potential complications.[8]
Symptomatic uncomplicated diverticular disease
editSUDD clinically presents with left lower abdominal pain and bowel habit changes (predominantly diarrhea). The pain is chronic and does not improve with bowel movement, which distinguishes SUDD from irritable bowel syndrome. There is no systemic inflammation in SUDD, evident by lack of fever, normal white blood count and inflammatory markers. Fecal calprotectin is increased and can be used to correlate with the severity of symptoms.[6]
Segmental colitis associated with diverticulosis
editSCAD typically presents with rectal bleeding with or without bowel habit changes. Fever is usually absent. Unlike other diverticular diseases, SCAD symptoms spontaneously resolve on its own without or with very limited pharmaceutical intervention. Endoscopic evaluation and biopsy are needed for diagnosis. They should show evidence of inflammation in the mucosa in-between diverticula, with sparing of the rectum and proximal colon.[13] Histopathological features of SCAD include tumor necrosis factor alpha overexpression and absence of granuloma. Laboratory workup would return normal white blood count, negative serological markers and negative anti-Saccharomyces cerevisiae antibodies,[14] distinguishing SCAD from autoimmune and other inflammatory bowel diseases.
Treatment
editDiverticulitis
editUncomplicated diverticulitis is generally treated conservatively with bowel rest and no antibiotics given recent studies have shown that antibiotics are likely not necessary.[15] Complicated diverticulitis is treated with antibiotics and may require surgical interventions such as abscess drainage or fistula repair.[8] Pain is managed with antispasmodics or acetaminophen, rather than NSAIDs (ibuprofen, aspirin, etc.).[16]
Antibiotics should be used selectively in most cases of uncomplicated diverticulitis. However, antibiotic use is strongly advised in immunocompromised patients.[11]
Colonoscopy is recommended 6–8 weeks after an episode of complicated diverticulitis or a first-ever episode of diverticulitis. The purpose of the procedure is to confirm diagnosis of diverticular disease and rule out other conditions like cancer.[17] Elective segmental colectomy can be considered in selective group of patients to reduce risk of recurrent diverticulitis. However, the procedure does not completely eliminate the risk of recurrence.[11]
Symptomatic uncomplicated diverticular disease
editCurrently there is no supported effective treatment for SUDD. Anti-inflammatory agent mesalamine and non-absorbable antibiotic rifaximin might improve symptoms and prevent acute diverticulitis. Probiotics could also be used to reduce symptoms but there is currently insufficient supporting evidence.[6]
Segmental colitis associated with diverticulosis
editSCAD is a benign and self-limited condition that resolves on its own. In ongoing or recurrent cases, medical treatments with antibiotics, mesalamine, and corticosteroids might be required.[14]
References
edit- ^ "Clinical manifestations and diagnosis of colonic diverticular disease". Literature review.
- ^ a b c d Piscopo, N; Ellul, P (September 2020). "Diverticular Disease: A Review on Pathophysiology and Recent Evidence". The Ulster Medical Journal. 89 (2): 83–88. PMC 7576390. PMID 33093692.
- ^ "Diverticulitis". Mayo Foundation for Medical Education and Research (MFMER). Retrieved 12 July 2021.
- ^ Golder, Mark; Burleigh, David E.; Belai, Abi; Ghali, Lucy; Ashby, Deborah; Lunniss, Peter J.; Navsaria, Harry A.; Williams, Norman S. (2003-06-07). "Smooth muscle cholinergic denervation hypersensitivity in diverticular disease". Lancet. 361 (9373): 1945–1951. doi:10.1016/S0140-6736(03)13583-0. ISSN 0140-6736. PMID 12801738.
- ^ "Colonic Diverticular Disease". www.clevelandclinicmeded.com. Retrieved 2024-03-05.
- ^ a b c d Calini, G; Abd El Aziz, MA; Paolini, L; Abdalla, S; Rottoli, M; Mari, G; Larson, DW (2023). "Symptomatic Uncomplicated Diverticular Disease (SUDD): Practical Guidance and Challenges for Clinical Management". Clinical and Experimental Gastroenterology. 16: 29–43. doi:10.2147/CEG.S340929. hdl:11585/921372. PMC 10066719. PMID 37013200.
- ^ Schembri, J; Bonello, J; Christodoulou, DK; Katsanos, KH; Ellul, P (2017). "Segmental colitis associated with diverticulosis: is it the coexistence of colonic diverticulosis and inflammatory bowel disease?". Annals of Gastroenterology. 30 (3): 257–261. doi:10.20524/aog.2017.0126. PMC 5411375. PMID 28469355.
- ^ a b c Sinclair, Aaron (December 2017). "Diverticular Disease of the Gastrointestinal Tract". Primary Care: Clinics in Office Practice. 44 (4): 643–654. doi:10.1016/j.pop.2017.07.007.
- ^ a b Rezapour, Mona; Ali, Saima; Stollman, Neil (15 March 2018). "Diverticular Disease: An Update on Pathogenesis and Management". Gut and Liver. 12 (2): 125–132. doi:10.5009/gnl16552. PMID 28494576.
- ^ Kvasnovsky, C. L.; Papagrigoriadis, S.; Bjarnason, I. (June 2014). "Increased diverticular complications with nonsteriodal anti-inflammatory drugs and other medications: a systematic review and meta-analysis". Colorectal Disease. 16 (6): O189-96. doi:10.1111/codi.12516. PMID 24320820.
- ^ a b c Peery, Anne F.; Shaukat, Aasma; Strate, Lisa L. (February 2021). "AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review". Gastroenterology. 160 (3): 906–911.e1. doi:10.1053/j.gastro.2020.09.059. PMC 7878331. PMID 33279517.
- ^ Sigurdsson, Snaevar; Alexandersson, Kristjan F.; Sulem, Patrick; Feenstra, Bjarke; Gudmundsdottir, Steinunn; Halldorsson, Gisli H.; Olafsson, Sigurgeir; Sigurdsson, Asgeir; Rafnar, Thorunn; Thorgeirsson, Thorgeir; Sørensen, Erik; Nordholm-Carstensen, Andreas; Burcharth, Jakob; Andersen, Jens; Jørgensen, Henrik Stig (2017-06-06). "Sequence variants in ARHGAP15, COLQ and FAM155A associate with diverticular disease and diverticulitis". Nature Communications. 8: 15789. Bibcode:2017NatCo...815789S. doi:10.1038/ncomms15789. ISSN 2041-1723. PMC 5467205. PMID 28585551.
- ^ Sbarigia, C; Ritieni, C; Annibale, B; Carabotti, M (20 September 2023). "Common Diagnostic Challenges and Pitfalls in Segmental Colitis Associated with Diverticulosis (SCAD)". Journal of Clinical Medicine. 12 (18): 6084. doi:10.3390/jcm12186084. PMC 10532061. PMID 37763023.
- ^ a b Freeman, Hugh J. (June 2023). "Segmental Colitis Associated with Diverticulosis (SCAD)". Current Gastroenterology Reports. 25 (6): 130–133. doi:10.1007/s11894-023-00871-y. PMC 10152430. PMID 37129830.
- ^ Eckmann, Jason D.; Shaukat, Aasma (2022-01-01). "Updates in the understanding and management of diverticular disease". Current Opinion in Gastroenterology. 38 (1): 48–54. doi:10.1097/MOG.0000000000000791. ISSN 1531-7056. PMID 34619712.
- ^ "Treatment for Diverticular Disease - NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 2024-03-05.
- ^ "Diagnosis of Diverticular Disease - NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 2024-03-05.