Diverticular Disease and Diverticulitis
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Diverticular disease and diverticulitis are conditions that affect the large intestine (colon) and involve the formation and inflammation of small bulges or pockets called diverticula.
- Diverticular Disease: Refers to when these diverticula cause symptoms such as abdominal pain and bloating.
- Diverticulitis: Occurs when the diverticula become inflamed or infected, leading to more severe symptoms.
Symptoms:
- Diverticular Disease:
- Lower abdominal pain, often on the left side.
- Feeling bloated.
- Many people with diverticula do not experience symptoms; this is called diverticulosis.
- Diverticulitis:
- Severe abdominal pain (typically left-sided).
- Fever (38°C / 100.4°F or higher).
- Diarrhoea or frequent bowel movements.
Causes:
- Diverticula are small bulges that form due to weakening of the large intestine’s walls, often from the pressure of hard stools passing through.
- They are common with age, with an estimated 5% of people having them by age 40 and 50% by age 80.
Risk Factors:
- Low-fibre diets can increase pressure in the colon, leading to the formation of diverticula.
- Genetics and dietary habits contribute, with a lower prevalence in countries with high-fibre diets.
Treatment:
Diverticular Disease:
- High-fibre Diet: Helps ease symptoms and prevent further complications.
- Paracetamol: Used for pain relief; other painkillers like aspirin or ibuprofen are discouraged due to potential stomach irritation.
- Consultation: If paracetamol is insufficient, seek advice from a GP.
Diverticulitis:
- Mild Cases: Usually treated with antibiotics at home.
- Severe Cases: May require hospitalization for complication management.
- Surgery: In rare cases, surgical removal of the affected intestine may be necessary due to serious complications like abscesses.
Who is Affected:
- Prevalence: Diverticular disease is common, particularly in people over 70.
- Gender and Age: Men under 50 are more commonly affected than women in the same age group, but overall, men and women are equally affected.
- Geography: Higher prevalence in Western countries compared to African and Asian regions, likely due to differences in diet and fibre intake.
Prevention:
- High-fibre Diet: Consuming at least 25g of fibre daily can significantly reduce the risk of hospital admission for complications in people aged 50-70.
- Lifestyle Changes: Maintaining a balanced diet rich in fruits, vegetables, and whole grains can promote digestive health and prevent complications related to diverticula.
In summary, diverticular disease and diverticulitis are manageable conditions with proper diet, lifestyle adjustments, and, when needed, medical treatment. Early intervention and preventive care, including dietary fibre intake, are essential in minimizing complications and improving overall digestive health.
Symptoms of Diverticular Disease and Diverticulitis
Diverticular disease and diverticulitis are related conditions that cause symptoms affecting the large intestine (colon). Here’s a breakdown of their symptoms:
1. Diverticulosis
- Asymptomatic Nature: Many people discover they have diverticula (small bulges in the colon) incidentally during tests such as a colonoscopy or CT scan for other reasons. In such cases, around 70%-80% of individuals remain symptom-free.
- Reassurance: Diverticula are common in people over 70 and do not increase the risk of cancer. A high-fibre diet can help reduce the risk of symptoms developing.
2. Diverticular Disease
- Abdominal Pain: The most common symptom is intermittent pain in the lower abdomen, typically on the lower left-hand side. The pain may worsen during eating or soon after meals, with relief often coming after passing stools or breaking wind.
- Bowel Habit Changes: People may experience a change in bowel habits, such as:
- Constipation or diarrhoea, or alternating episodes of both.
- Morning trips to the toilet where stools resemble ‘rabbit pellets.’
- Bloating: Feeling bloated is common.
- Rectal Bleeding: In some cases, dark purple blood may appear in the rectum after cramping pain and diarrhoea. Although rare, this symptom can lead to hospital admission.
Important Note: Diverticular disease does not cause weight loss. If you notice weight loss, rectal bleeding, or frequent changes in bowel habits, see your GP for further evaluation.
3. Diverticulitis
- Constant, Severe Pain: Unlike diverticular disease, diverticulitis causes persistent and severe pain, often starting around the belly button and moving to the lower left side of the abdomen. For some East Asian individuals, the pain may be on the lower right side due to genetic variations.
- Other Symptoms:
- High temperature (fever) of 38°C (100.4°F) or above.
- Fatigue and general unwellness.
- Nausea or vomiting.
- Development: Symptoms of diverticulitis often develop over one or two days and may occur after previously experiencing symptoms of diverticular disease.
When to Seek Medical Advice
- For Diverticulitis: Contact your GP immediately if you have symptoms of diverticulitis.
- For Diverticular Disease: If you have already been diagnosed and recognize familiar symptoms, home treatment may suffice. However, if not previously diagnosed, see your GP to rule out other potential conditions, including:
- Stomach ulcers.
- Pancreatitis.
- Cholecystitis.
- Bowel cancer.
- Irritable bowel syndrome (IBS), which can present with similar symptoms.
By understanding the symptoms and when to seek medical advice, individuals can better manage and address these digestive conditions, potentially reducing discomfort and preventing complications.
Causes of Diverticular Disease and Diverticulitis
Diverticular Disease is characterized by the development of small bulges or pockets called diverticula in the large intestine (colon), which can become inflamed and lead to symptoms. When these pockets become infected, the condition progresses to diverticulitis.
Why Diverticula Develop:
- Fiber Intake: The exact cause of diverticula is unclear, but they are commonly linked to insufficient dietary fiber intake.
- Role of Fiber: Fiber adds bulk and softness to stools, making them easier to pass through the colon with less pressure. When stools are hard and small, the large intestine has to exert more pressure to move them. This increased pressure can create weak spots in the outer muscle layer of the colon, allowing the inner layer (mucosa) to push through, forming diverticula.
- Regional Prevalence: Diverticular disease is more prevalent in Western countries where low-fiber diets are common, though direct clinical evidence linking fiber intake to diverticula formation is limited.
Causes of Diverticular Disease:
- Only about 1 in 4 people with diverticula experience symptoms. It’s hypothesized that diverticular disease may involve chronic, low-level inflammation of diverticula, though its symptoms can overlap with those of irritable bowel syndrome (IBS).
- Risk Factors:
- Smoking: Smokers may be at a higher risk.
- Obesity: Excess body weight appears to increase the risk of diverticular disease.
- Constipation History: People with a history of constipation may be more prone to developing diverticula.
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Regular use of painkillers such as ibuprofen or naproxen may raise the risk.
- Genetics: A family history of diverticular disease, particularly when it develops before age 50, may indicate a genetic predisposition.
- Exact Mechanism: The reasons why these factors increase the likelihood of developing diverticular disease are not fully understood.
Causes of Diverticulitis:
- Infection of Diverticula: Diverticulitis arises when one or more diverticula become infected.
- Possible Cause of Infection: The infection often occurs when a hard piece of stool or undigested food becomes lodged in a diverticulum. This allows bacteria within the stool to multiply and spread, leading to inflammation and infection.
By understanding these causes and risk factors, individuals can take proactive measures, such as increasing dietary fiber intake, to potentially lower their risk of developing diverticular disease and diverticulitis. Managing lifestyle factors, like maintaining a healthy weight and avoiding smoking, may also contribute to reducing risk.
Diagnosing Diverticular Disease and Diverticulitis
Diagnosing diverticular disease and diverticulitis can be challenging because their symptoms often overlap with other gastrointestinal conditions like irritable bowel syndrome (IBS). Proper diagnosis is crucial to distinguish these conditions and identify the appropriate treatment.
Initial Diagnostic Steps:
- Blood Tests: Your general practitioner (GP) may recommend blood tests to exclude other conditions such as:
- Coeliac Disease: Caused by an abnormal immune response to gluten.
- Bowel Cancer: To rule out cancerous changes in the bowel.
- Symptom-Based Treatment: In some cases, your GP might offer treatments for both IBS and diverticular disease simultaneously due to symptom similarities.
Colonoscopy:
- Procedure: A colonoscopy involves inserting a thin tube with a camera (a colonoscope) into your rectum to examine the colon. It allows doctors to see the lining of the colon directly and check for the presence of diverticula, inflammation, or other abnormalities.
- Preparation: You will need to take a laxative before the procedure to clear out your bowels.
- Comfort Measures: Colonoscopies are usually not painful, but they can be uncomfortable. You may be given pain-relief medication and a sedative to help you relax and minimize discomfort.
CT Pneumocolon or Colonography:
- CT Scan Overview: This method uses X-rays and a computer to generate detailed images of the colon, confirming the presence of diverticula.
- Preparation: As with a colonoscopy, a laxative will be given to clear out your bowels beforehand.
- Procedure: A tube is inserted into your rectum to pump air, and scans are taken with you lying in different positions.
- Contrast Dye: You may receive an injection of a contrast dye to enhance image clarity, though it is not always necessary.
Diagnosing Diverticulitis:
- If you have a previous history of diverticular disease, your GP can typically diagnose diverticulitis based on symptoms and a physical exam. A blood test may be performed, as elevated white blood cell counts indicate infection.
- If symptoms are mild, your GP will usually treat you at home, and recovery often occurs within four days.
- If you do not have a previous diagnosis of diverticular disease or if symptoms are severe, further tests may be required. This may involve:
- Hospital Referral: For additional blood tests and imaging.
- Ultrasound and CT Scans: These may be used to check for complications like perforation (a hole in the intestine) or an abscess (a collection of infected fluid).
By thoroughly evaluating your symptoms and using imaging tests when necessary, healthcare providers can accurately diagnose diverticular disease and diverticulitis and create a tailored treatment plan to address your condition effectively.
Treating Diverticular Disease and Diverticulitis
The treatment options for diverticular disease and diverticulitis vary depending on the severity of your symptoms. Here’s an overview of the recommended approaches:
1. Treatment for Diverticular Disease:
- At-Home Care:
- Most cases can be managed at home.
- Pain Management: The recommended painkiller for symptom relief is paracetamol. Avoid non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen, as these can irritate the stomach and increase the risk of internal bleeding.
- Dietary Changes:
- High-Fibre Diet: Eating a high-fibre diet can help control symptoms. Improvements may be noticed within a few days, but it can take about a month to see the full benefits.
- If you have constipation, you may be prescribed bulk-forming laxatives. These may cause flatulence (wind) and bloating, so drink plenty of fluids to avoid any digestive obstructions.
- Bleeding Complications:
- Heavy or constant rectal bleeding occurs in about 1 in 20 cases due to weakened blood vessels in the colon. Symptoms of heavy bleeding include dizziness, mental confusion, pale clammy skin, and shortness of breath. Seek immediate medical attention if this occurs.
2. Treatment for Diverticulitis:
- Home Treatment for Mild Cases:
- Antibiotics may be prescribed to treat the infection.
- Use paracetamol for pain relief and avoid NSAIDs.
- Your GP may suggest a fluid-only diet initially to reduce symptoms and gradually reintroduce solid foods over a few days. Transition to a low-fibre diet for 3-4 days during recovery before returning to a high-fibre diet.
- Hospital Treatment for Severe Cases:
- Hospital admission may be necessary if:
- Pain is not controlled by paracetamol.
- You cannot maintain hydration or take oral antibiotics.
- You have a weakened immune system or general poor health.
- Symptoms persist after two days of home treatment.
- Treatment usually involves intravenous antibiotics and hydration via an IV drip. Most people start to feel better within 2-3 days.
- Hospital admission may be necessary if:
3. Surgical Treatment:
- Elective Surgery:
- Surgery used to be recommended as a preventative measure for those with two episodes of diverticulitis but is no longer routine due to associated risks.
- Surgery may still be recommended for people with a history of serious complications, early onset of symptoms, or weakened immune systems.
- Emergency Surgery:
- In severe cases where there is a perforation (hole) in the bowel, emergency surgery may be necessary, which can result in serious abdominal pain and requires immediate hospital intervention.
- Types of Surgery:
- Colectomy: Removal of the affected section of the large intestine. This can be done using:
- Open Colectomy: Involves a large incision in the abdomen.
- Laparoscopic Colectomy (Keyhole Surgery): Involves small incisions and is generally associated with faster recovery and less pain.
- Stoma Surgery:
- If healing is required before reattaching the intestine or if a large portion is removed, a stoma (opening in the abdomen for waste) may be created temporarily or permanently.
- Colectomy: Removal of the affected section of the large intestine. This can be done using:
4. Recovery and Outcome of Surgery:
- Elective (non-emergency) surgeries usually have a good success rate. However, approximately 1 in 12 people may experience a recurrence of symptoms.
- The outcome for emergency surgeries depends on the patient’s condition at the time of operation.
Effective treatment for diverticular disease and diverticulitis involves careful management of symptoms, dietary adjustments, and monitoring for complications. Surgery is reserved for more severe or recurring cases and should be discussed thoroughly with a healthcare provider to weigh the risks and benefits.
Complications of Diverticular Disease and Diverticulitis
Complications occur in about 1 in 5 people with diverticulitis, and those under the age of 50 are more at risk. Here is a detailed overview of potential complications:
1. Bleeding:
- Around 15% of people with diverticular disease or diverticulitis experience bleeding. This bleeding is often painless and quick to resolve, with 70% to 80% of cases resolving on their own.
- If bleeding does not stop on its own, it may require an emergency blood transfusion.
- Severe cases may necessitate hospital admission for monitoring.
2. Urinary Problems:
- Inflammation in the bowel can cause it to press against the bladder, leading to:
- Dysuria: Pain during urination.
- Increased frequency of urination.
- Air in the urine (rare).
3. Abscess:
- This is the most common complication of diverticulitis. An abscess is a collection of pus outside the large intestine.
- Treatment:
- Abscesses are typically treated using Percutaneous Abscess Drainage (PAD).
- A radiologist uses ultrasound or CT scans to locate the abscess.
- A fine needle and tube are used to drain pus under local anaesthetic. This may need to be repeated several times.
- Small abscesses (under 4 cm) may sometimes be treated with antibiotics alone.
4. Fistula:
- A fistula is an abnormal connection that forms between two parts of the body, such as the intestine and the bladder or abdominal wall.
- Fistulas occur when infected tissues stick together, then heal improperly.
- They are potentially serious because they can enable bacteria to spread and cause infections (e.g., bladder infections or cystitis).
- Treatment: Surgery to remove the affected section of the colon.
5. Peritonitis:
- In rare cases, an infected diverticulum can rupture, leading to an infection of the lining of the abdomen (peritonitis).
- This condition is life-threatening and requires immediate treatment with antibiotics and possibly surgery to drain pus or perform a colostomy.
6. Intestinal Obstruction:
- Scarring from an infection may partially or totally block the large intestine.
- Total Obstruction: A medical emergency as it can lead to tissue decay and splitting of the large intestine, resulting in peritonitis.
- Partial Obstruction: This condition requires treatment to avoid serious digestive issues and pain.
- Surgery: In some cases, the blocked section can be removed. More extensive scarring may require a temporary or permanent colostomy.
These complications highlight the importance of monitoring diverticular disease and managing symptoms with appropriate care and prompt medical attention to prevent severe outcomes.
Preventing Diverticular Disease and Diverticulitis
Managing and potentially preventing diverticular disease and diverticulitis largely revolves around maintaining a high-fiber diet, which can help improve digestive health and reduce symptoms associated with diverticula. Here’s a detailed guide to prevention strategies:
1. High-Fiber Diet
- Daily Fiber Intake: Adults should aim for 18g to 30g of fiber per day. Your GP can provide a more precise target based on your individual height and weight.
- Gradual Increase: Increase fiber intake gradually to prevent side effects like bloating and gas. Drink plenty of fluids to reduce any discomfort from a higher fiber intake.
2. Recommended Sources of Fiber
Fruits and Vegetables:
- Fresh Fruit (with typical fiber content per portion):
- Medium-sized avocado: 4.9g
- Medium-sized pear (with skin): 3.7g
- Medium-sized orange: 2.7g
- Medium-sized apple (with skin): 2g
- 2 handfuls of raspberries (80g): 2g
- Medium-sized banana: 1.7g
- Small glass of tomato juice (200ml): 1.2g
- Dried Fruit:
- 3 whole apricots: 5g
- 3 whole prunes: 4.6g
- Vegetables (typical portion sizes and fiber content):
- Half-can of baked beans (200g): 7.4g
- 3 tablespoons of boiled red kidney beans: 5.4g
- 3 heaped tablespoons of boiled peas: 3.6g
- 4 heaped tablespoons of boiled French beans: 3.3g
- 8 boiled Brussel sprouts: 2.5g
- Medium-sized boiled potato: 2.4g
- 4 heaped tablespoons of boiled spring greens: 2.1g
- 3 heaped tablespoons of boiled, sliced carrots: 2g
- Fresh Fruit (with typical fiber content per portion):
Nuts (typical fiber content per portion):
- 20 almonds: 2.4g
- 1 tablespoon of plain peanuts: 1.6g
- 1 tablespoon of mixed nuts: 1.5g
- 10 Brazil nuts: 1.4g
Breakfast Cereals:
- Medium-sized bowl of All-Bran: 9.8g
- 2 pieces of Shredded Wheat: 4.3g
- Medium-sized bowl of Bran Flakes: 3.9g
- 2 Weetabix: 3.6g
- Medium-sized bowl of muesli (no added sugar): 3.4g
- Medium-sized bowl of porridge (made with milk or water): 2.3g
Starchy Foods:
- 4 crispbreads: 4.2g
- 1 piece (75g) of wholemeal pitta bread: 3.9g
- Medium portion (200g) of plain, fresh-cooked pasta: 3.8g
- 2 slices of wholemeal bread: 3.5g
- 1 piece of naan bread: 3.2g
- 2 slices of brown bread: 2.5g
- Medium portion (200g) of boiled brown rice: 1.6g
3. Potential Triggers and Restrictions
- Nuts, Corn, and Seeds: Individuals with established diverticular disease may need to monitor their intake of nuts, corn, and seeds, as these may block diverticular openings and potentially cause diverticulitis in some cases. However, there is limited scientific evidence supporting this restriction.
4. Supplements
- Fibre Supplements: Available at pharmacies, these may contain around 2.5g of fiber per tablespoon. Long-term supplements can be prescribed by your GP if needed.
5. Probiotics and Lifestyle Considerations
- Probiotics: Although some recommend probiotics to promote gut health, there is limited evidence regarding their effectiveness in preventing diverticular disease.
- Healthy Lifestyle Tips:
- Maintain hydration by drinking plenty of fluids.
- Avoid processed foods and prioritize whole grains.
- Manage body weight and avoid smoking.
- Exercise regularly to support overall digestive health.
- Limit red meat intake if suggested by your healthcare provider.
By adhering to a fiber-rich diet and maintaining healthy lifestyle habits, individuals can reduce the risk of developing diverticular disease and help manage any existing symptoms. Always consult with a healthcare provider for personalized recommendations.
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