Diverticular disease | |
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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 |
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.
The signs and symptoms of diverticular disease stem from inflammation and irritation of the colonic tissues, which can manifest as:
Acute diverticulitis is thought to arise from either trauma or lack of blood flow to the existing diverticulum in the colon.
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]
Similar 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]
SCAD, 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]
Many risk factors contribute to the development and severity of diverticular disease, such as
Diverticulitis 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]
SUDD 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]
SCAD 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.
Uncomplicated 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]
Currently 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]
SCAD 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]
Crohn's disease is a type of inflammatory bowel disease (IBD) that may affect any segment of the gastrointestinal tract. Symptoms often include abdominal pain, diarrhea, fever, abdominal distension, and weight loss. Complications outside of the gastrointestinal tract may include anemia, skin rashes, arthritis, inflammation of the eye, and fatigue. The skin rashes may be due to infections as well as pyoderma gangrenosum or erythema nodosum. Bowel obstruction may occur as a complication of chronic inflammation, and those with the disease are at greater risk of colon cancer and small bowel cancer.
Ulcerative colitis (UC) is one of the two types of inflammatory bowel disease (IBD), with the other type being Crohn's disease. It is a long-term condition that results in inflammation and ulcers of the colon and rectum. The primary symptoms of active disease are abdominal pain and diarrhea mixed with blood (hematochezia). Weight loss, fever, and anemia may also occur. Often, symptoms come on slowly and can range from mild to severe. Symptoms typically occur intermittently with periods of no symptoms between flares. Complications may include abnormal dilation of the colon (megacolon), inflammation of the eye, joints, or liver, and colon cancer.
Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications may include shock and acute respiratory distress syndrome.
Enteritis is inflammation of the small intestine. It is most commonly caused by food or drink contaminated with pathogenic microbes, such as Serratia, but may have other causes such as NSAIDs, radiation therapy as well as autoimmune conditions like coeliac disease. Symptoms include abdominal pain, cramping, diarrhoea, dehydration, and fever. Related diseases of the gastrointestinal system involve inflammation of the stomach and large intestine.
Hematochezia is a form of blood in stool, in which fresh blood passes through the anus while defecating. It differs from melena, which commonly refers to blood in stool originating from upper gastrointestinal bleeding (UGIB). The term derives from Greek αἷμα ("blood") and χέζειν. Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper gastrointestinal bleed. The difference between hematochezia and rectorrhagia is that rectal bleeding is not associated with defecation; instead, it is associated with expulsion of fresh bright red blood without stools. The phrase bright red blood per rectum is associated with hematochezia and rectorrhagia.
Diverticulitis, also called colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—diverticula—that can develop in the wall of the large intestine. Symptoms typically include lower abdominal pain of sudden onset, but the onset may also occur over a few days. There may also be nausea, diarrhea or constipation. Fever or blood in the stool suggests a complication. People may experience a single attack, repeated attacks, or ongoing "smouldering" diverticulitis.
Diverticulosis is the condition of having multiple pouches (diverticula) in the colon that are not inflamed. These are outpockets of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. Diverticula do not cause symptoms in most people. Diverticular disease occurs when diverticula become clinically inflamed, a condition known as diverticulitis.
Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum; and the accessory organs of digestion, the liver, gallbladder, and pancreas.
Mesalazine, also known as mesalamine or 5-aminosalicylic acid (5-ASA), is a medication used to treat inflammatory bowel disease, including ulcerative colitis and Crohn's disease. It is generally used for mildly to moderately severe disease. It is taken by mouth or rectally. The formulations which are taken by mouth appear to be similarly-effective.
In medicine or biology, a diverticulum is an outpouching of a hollow structure in the body. Depending upon which layers of the structure are involved, diverticula are described as being either true or false.
Toxic megacolon is an acute form of colonic distension. It is characterized by a very dilated colon (megacolon), accompanied by abdominal distension (bloating), and sometimes fever, abdominal pain, or shock.
A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or significant pain when the abdomen is touched.
Gastrointestinal perforation, also known as gastrointestinal rupture, is a hole in the wall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from the mouth to the anus. Symptoms of gastrointestinal perforation commonly include severe abdominal pain, nausea, and vomiting. Complications include a painful inflammation of the inner lining of the abdominal wall and sepsis.
Blood in stool looks different depending on how early it enters the digestive tract—and thus how much digestive action it has been exposed to—and how much there is. The term can refer either to melena, with a black appearance, typically originating from upper gastrointestinal bleeding; or to hematochezia, with a red color, typically originating from lower gastrointestinal bleeding. Evaluation of the blood found in stool depends on its characteristics, in terms of color, quantity and other features, which can point to its source, however, more serious conditions can present with a mixed picture, or with the form of bleeding that is found in another section of the tract. The term "blood in stool" is usually only used to describe visible blood, and not fecal occult blood, which is found only after physical examination and chemical laboratory testing.
Lower gastrointestinal bleeding (LGIB) is any form of gastrointestinal bleeding in the lower gastrointestinal tract. LGIB is a common reason for seeking medical attention at a hospital's emergency department. LGIB accounts for 30–40% of all gastrointestinal bleeding and is less common than upper gastrointestinal bleeding (UGIB). It is estimated that UGIB accounts for 100–200 per 100,000 cases versus 20–27 per 100,000 cases for LGIB. Approximately 85% of lower gastrointestinal bleeding involves the large intestine, 10% are from bleeds that are actually upper gastrointestinal bleeds, and 3–5% involve the small intestine.
Neutropenic enterocolitis, also known as typhlitis, is an inflammation of the cecum that may be associated with infection. It is particularly associated with neutropenia, a low level of neutrophil granulocytes in the blood.
Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply (ischemia). Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Causes of the reduced blood flow can include changes in the systemic circulation or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified.
Management of ulcerative colitis involves first treating the acute symptoms of the disease, then maintaining remission. Ulcerative colitis is a form of colitis, a disease of the intestine, specifically the large intestine or colon, that includes characteristic ulcers, or open sores, in the colon. The main symptom of active disease is usually diarrhea mixed with blood, of gradual onset which often leads to anaemia. Ulcerative colitis is, however, a systemic disease that affects many parts of the body outside the intestine.
Hinchey Classification is used to describe perforations of the colon due to diverticulitis. The classification was developed by Dr. E John Hinchey (1934–present), a general surgeon at the Montreal General Hospital and professor of surgery at McGill University.
Segmental colitis associated with diverticulosis (SCAD) is a condition characterized by localized inflammation in the colon, which spares the rectum and is associated with multiple sac-like protrusions or pouches in the wall of the colon (diverticulosis). Unlike diverticulitis, SCAD involves inflammation of the colon between diverticula, while sparing the diverticular orifices. SCAD may lead to abdominal pain, especially in the left lower quadrant, intermittent rectal bleeding and chronic diarrhea.