What is a diverticulum?
A diverticulum is a pouch that either occurs naturally or is created by herniation (rupture in smooth muscle tissue through which a body structure protrudes) of an inner lining or mucous membrane. They can appear in the lining of the colon and large intestine, bulging through weak spots.
How do they develop?
While the specific cause is unknown, it can be safely said that the development of diverticula involves environmental and lifestyle factors. They include lack of dietary fibre, increased luminal pressure, age-related factors and hypersegmentation of cells in the body. Among the Asian population, incidence of diverticula is more common in the right colon.
What are diverticulitis and diverticulosis?
The most common symptom of diverticulitis is left lower abdominal pain. The most common sign on examination is tenderness in the lower left side of the abdomen. Usually, the pain is severe and comes on suddenly, but it can also be mild which can become worse over several days. The intensity of the pain can fluctuate. The person may experience cramping, nausea, vomiting, fever, chills, or a change in bowel habits. Obstipation (severe constipation resulting from an obstruction in the intestines) and occasional diarrhoea are common symptoms. Bleeding is uncommon, although it is not ruled out.
Most people with diverticulosis meanwhile, do not have any discomfort or symptoms. However, some people may experience crampy pain or discomfort in the lower abdomen, bloating, and constipation.Other conditions such as irritable bowel syndrome and stomach ulcers cause similar problems, so the symptoms do not always mean a person has diverticulosis. People with chronic symptoms need doctor’s advice.
What is the course of action?
Most initial presentations are uncomplicated. Of these, the majority can be effectively managed medically. After successful management, about one-third will remain asymptomatic, about one-third will have discomfort from time to time, and some may require surgery.
How do they decide if a patient needs surgery?
Fistula, abscess, obstruction and peritonitis (inflammation of the peritoneum (the transparent membrane that lines the abdominal cavity) from perforation are common complications of diverticulitis, which may require surgery.
How should symptomatic diverticulitis be managed?
Most clinicians emphasise the benefits of a high fibre diet, regardless of presence or absence of symptoms. Abdominal pain is thought to be related to spasm or distension of the colon. Antispasmodics help in pain relief. Patients should not be advised to avoid foods containing seeds and nuts, as there is no particular scientific basis to it. Such incorrect advice also eliminates many nutritious and high fibre foods.
What imaging modalities are used?
CT or computed tomography (a method of examining body organs by scanning them with X-rays and using a computer to construct a series of cross-sectional scans along a single axis) is the test of choice for diagnosis of simple and complicated diverticulitis. CT offers the added advantage of providing information on other diseases, such as in ischemic colitis (a disorder that develops when blood flow to a part of your large intestine or the colon is reduced), mesenteric thrombosis (a blood clot in the major veins that drain blood from the intestine), tubo-ovarian abscess (an infection in either the ovaries or the fallopian tubes), pancreatitis (inflammation of the pancreas), etc. Ultrasound of the abdomen and pelvis are also useful. Contrast examination and colonoscopy can also be used, but one has to be careful with them in complicated diverticulitis.
What is the diagnosis?
Complicated diverticulitis can develop fistulas in the bladder, small bowel and vagina. It can develop abscess and stricture (abnormal narrowing of a canal or passageway) which can mimic Crohn’s disease (inflammatory disease of the intestines). Carcinoma has to be differentiated from this, though.
Are these diseases very common?
Diverticulosis is known to increase with age. It can be seen among five per cent people by the age of 40, 30 per cent by 60 years, and 65 per cent by 85 years of age in western societies. In India though, the rates are much lower