Diverticular Disease

       Diverticular disease is a condition that occurs when a person has problems from small pouches, or sacs, that have formed and pushed outward through weak spots in the colon wall.

Diverticular disease is a condition that occurs when a person has problems from small pouches, or sacs, that have formed and pushed outward through weak spots in the colon wall. Each pouch is called a diverticulum. Multiple pouches are called diverticula.

The colon is part of the large intestine. The large intestine absorbs water from stool and changes it from a liquid to a solid form. Diverticula are most common in the lower part of the colon, called the sigmoid colon.

The problems that occur with diverticular disease include diverticulitis and diverticular bleeding. Diverticulitis occurs when the diverticula become inflamed, or irritated and swollen, and infected. Diverticular bleeding occurs when a small blood vessel within the wall of a diverticulum bursts.

What is diverticulosis?

When a person has diverticula that do not cause diverticulitis or diverticular bleeding, the condition is called diverticulosis. Most people with diverticulosis do not have symptoms. Some people with diverticulosis have constipation or diarrhea. People may also have chronic

• cramping or pain in the lower abdomen—the area between the chest and hips
• bloating

Other conditions, such as irritable bowel syndrome and stomach ulcers, cause similar problems, so these symptoms do not always mean a person has diverticulosis. People with these symptoms should see their health care provider.

What causes diverticulosis and diverticular disease?

Scientists are not certain what causes diverticulosis and diverticular disease. For more than 50 years, the most widely accepted theory was that a low-fiber diet led to diverticulosis and diverticular disease. Diverticulosis and diverticular disease were first noticed in the United States in the early 1900s, around the time processed foods were introduced into the American diet. Consumption of processed foods greatly reduced Americans’ fiber intake. Diverticulosis and diverticular disease are common in Western and industrialized countries—particularly the United States, England, and Australia—where low-fiber diets are common. The condition is rare in Asia and Africa, where most people eat high-fiber diets.1 Two large studies also indicate that a low-fiber diet may increase the chance of developing diverticular disease.2

However, a recent study found that a low-fiber diet was not associated with diverticulosis and that a high-fiber diet and more frequent bowel movements may be linked to an increased rather than decreased chance of diverticula.3

Other studies have focused on the role of decreased levels of the neurotransmitter serotonin in causing decreased relaxation and increased spasms of the colon muscle. A neurotransmitter is a chemical that helps brain cells communicate with nerve cells. However, more studies are needed in this area.

Studies have also found links between diverticular disease and obesity, lack of exercise, smoking, and certain medications including nonsteroidal anti-inflammatory drugs, such as aspirin, and steroids.3
Scientists agree that with diverticulitis, inflammation may begin when bacteria or stool get caught in a diverticulum. In the colon, inflammation also may be caused by a decrease in healthy bacteria and an increase in disease-causing bacteria. This change in the bacteria may permit chronic inflammation to develop in the colon.

How are diverticulosis and diverticular disease diagnosed?

Diverticulosis

Health care providers often find diverticulosis during a routine x ray or a colonoscopy, a test used to look inside the rectum and entire colon to screen for colon cancer or polyps or to evaluate the source of rectal bleeding.

Diverticular Disease

Based on symptoms and severity of illness, a person may be evaluated and diagnosed by a primary care physician, an emergency department physician, a surgeon, or a gastroenterologist—a doctor who specializes in digestive diseases.

The health care provider will ask about the person’s health, symptoms, bowel habits, diet, and medications, and will perform a physical exam, which may include a rectal exam. A rectal exam is performed in the health care provider’s office; anesthesia is not needed. To perform the exam, the health care provider asks the person to bend over a table or lie on one side while holding the knees close to the chest. The health care provider slides a gloved, lubricated finger into the rectum. The exam is used to check for pain, bleeding, or a blockage in the intestine.

The health care provider may schedule one or more of the following tests:

• Blood test. A blood test involves drawing a person’s blood at a health care provider’s office, a commercial facility, or a hospital and sending the sample to a lab for analysis. The blood test can show the presence of inflammation or anemia—a condition in which red blood cells are fewer or smaller than normal, which prevents the body’s cells from getting enough oxygen.
• Computerized tomography (CT) scan. A CT scan of the colon is the most common test used to diagnose diverticular disease. CT scans use a combination of x rays and computer technology to create three-dimensional (3–D) images. For a CT scan, the person may be given a solution to drink and an injection of a special dye, called contrast medium. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the x rays are taken. The procedure is performed in an outpatient center or a hospital by an x-ray technician, and the images are interpreted by a radiologist—a doctor who specializes in medical imaging. Anesthesia is not needed. CT scans can detect diverticulosis and confirm the diagnosis of diverticulitis.
• Lower gastrointestinal (GI) series. A lower GI series is an x-ray exam that is used to look at the large intestine. The test is performed at a hospital or an outpatient center by an x-ray technician, and the images are interpreted by a radiologist. Anesthesia is not needed. The health care provider may provide written bowel prep instructions to follow at home before the test. The person may be asked to follow a clear liquid diet for 1 to 3 days before the procedure. A laxative or enema may be used before the test. A laxative is medication that loosens stool and increases bowel movements. An enema involves flushing water or laxative into the rectum using a special squirt bottle. These medications cause diarrhea, so the person should stay close to a bathroom during the bowel prep.
  For the test, the person will lie on a table while the radiologist inserts a flexible tube into the person’s anus. The colon is filled with barium, making signs of diverticular disease show up more clearly on x rays.
  For several days, traces of barium in the large intestine can cause stools to be white or light colored. Enemas and repeated bowel movements may cause anal soreness. A health care provider will provide specific instructions about eating and drinking after the test.
• Colonoscopy. The test is performed at a hospital or an outpatient center by a gastroenterologist. Before the test, the person’s health care provider will provide written bowel prep instructions to follow at home. The person may need to follow a clear liquid diet for 1 to 3 days before the test. The person may also need to take laxatives and enemas the evening before the test.
  In most cases, light anesthesia, and possibly pain medication, helps people relax for the test. The person will lie on a table while the gastroenterologist inserts a flexible tube into the anus. A small camera on the tube sends a video image of the intestinal lining to a computer screen. The test can show diverticulosis and diverticular disease.
  Cramping or bloating may occur during the first hour after the test. Driving is not permitted for 24 hours after the test to allow the anesthesia time to wear off. Before the appointment, people should make plans for a ride home. Full recovery is expected by the next day, and people should be able to go back to their normal diet.

How are diverticulosis and diverticular disease treated?

A health care provider may treat the symptoms of diverticulosis with a high-fiber diet or fiber supplements, medications, and possibly probiotics. Treatment for diverticular disease varies, depending on whether a person has diverticulitis or diverticular bleeding.

Diverticulosis

High-fiber diet. Studies have shown that a high-fiber diet can help prevent diverticular disease in people who already have diverticulosis.2 A health care provider may recommend a slow increase in dietary fiber to minimize gas and abdominal discomfort. For more information about fiber-rich foods, see “Eating, Diet, and Nutrition.”

Fiber supplements. A health care provider may recommend taking a fiber product such as methylcellulose (Citrucel) or psyllium (Metamucil) one to three times a day. These products are available as powders, pills, or wafers and provide 0.5 to 3.5 grams of fiber per dose. Fiber products should be taken with at least 8 ounces of water.

Medications. A number of studies suggest the medication mesalazine (Asacol), given either continuously or in cycles, may be effective at reducing abdominal pain and GI symptoms of diverticulosis. Research has also shown that combining mesalazine with the antibiotic rifaximin (Xifaxan) can be significantly more effective than using rifaximin alone to improve a person’s symptoms and maintain periods of remission, which means being free of symptoms.4

Probiotics. Although more research is needed, probiotics may help treat the symptoms of diverticulosis, prevent the onset of diverticulitis, and reduce the chance of recurrent symptoms. Probiotics are live bacteria, like those normally found in the GI tract. Probiotics can be found in dietary supplements—in capsules, tablets, and powders—and in some foods, such as yogurt.

To help ensure coordinated and safe care, people should discuss their use of complementary and alternative medical practices, including their use of dietary supplements and probiotics, with their health care provider. Read more at www.nccam.nih.gov/health/probiotics.

Tips for talking with health care providers are available at www.nccam.nih.gov/timetotalk.

Diverticular Bleeding

Diverticular bleeding is rare. Bleeding can be severe; however, it may stop by itself and not require treatment. A person who has bleeding from the rectum—even a small amount—should see a health care provider right away.

To treat the bleeding, a colonoscopy may be performed to identify the location of and stop the bleeding. A CT scan or angiogram also may be used to identify the site of the bleeding. A traditional angiogram is a special kind of x ray in which a thin, flexible tube called a catheter is threaded through a large artery, often from the groin, to the area of bleeding. Contrast medium is injected through the catheter so the artery shows up more clearly on the x ray. The procedure is performed in a hospital or an outpatient center by an x-ray technician, and the images are interpreted by a radiologist. Anesthesia is not needed, though a sedative may be given to lessen anxiety during the procedure.

If the bleeding does not stop, abdominal surgery with a colon resection may be necessary. In a colon resection, the surgeon removes the affected part of the colon and joins the remaining ends of the colon together; general anesthesia is used. A blood transfusion may be needed if the person has lost a significant amount of blood.

Diverticulitis

Diverticulitis with mild symptoms and no complications usually requires a person to rest, take oral antibiotics, and be on a liquid diet for a period of time. If symptoms ease after a few days, the health care provider will recommend gradually adding solid foods back into the diet.

Severe cases of diverticulitis with acute pain and complications will likely require a hospital stay. Most cases of severe diverticulitis are treated with intravenous (IV) antibiotics and a few days without food or drink to help the colon rest. If the period without food or drink is longer, the person may be given parenteral nutrition—a method of providing an IV liquid food mixture through a special tube in the chest. The mixture contains proteins, carbohydrates, fats, vitamins, and minerals.

If you have any questions or wish to schedule an appointment, please do not hesitate to call the office at (706) 548-0058. Remember that we usually require that you see a primary care physician (your family doctor or PCP) before we can schedule you. If you are having a medical emergency, get medical attention immediately at your nearest healthcare provider:

Athens Regional Medical Center: (706) 475-7000
St. Mary's Hospital: (706) 354-3000

This informational material is taken from the National Digestive Diseases Information Clearinghouse, a division of the U.S. Department of Health and Human Resources.

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