History

Fact Explanation
Dietary history Symptomatic disease is seen more commonly in those who consume insoluble dietary fiber. The incidence of diverticular disease is much less in vegetarians and those who consume high fiber in the diet [1]. The less fiber dietary pattern may be the reason for high prevalence of diverticular disease in the western countries [2].
Family history of diverticular disease Although no strong association is seen, genetic factors may play a role in the inheritance of diverticular disease [3].
Sedentary life style Lack of physical activity has shown some association with the occurrence of diverticular disease [1].
Abdominal pain Seen in symptomatic diverticular disease. The pain is thought to be caused by increased intra-abdominal pressure and increased bowel motility index [4]. Typical pain is colicky in nature which is aggregated after meals and relieved after passage of flatus or a bowel movement [1]. Note: about 85% of patients with diverticula have asymptomatic disease whereas only 15% present with symptoms [1]. Diverticulitis : Infection of the perforated diverticulum causes a constant pain of acute onset usually felt on the left lower quadrant [1]. Note: Although the sigmoid colon is affected more, the right sided pain can also occur specially in the Asian population and those who are less than 60 years [5]. Also right upper quadrant pain with persistent fever should alert on the possibility of pyogenic liver abscess, which is a complication of diverticulitis [1].
Bloating This may be due to increased intra abdominal pressure [1].
Change in bowel habits Seen in both symptomatic diverticular disease and diverticulitis. Patients mostly present with constipation than diarrhea in symptomatic diverticular disease [1].
Fullness/ tenderness in the left lower quadrant This is because the sigmoid colon is affected more [1].
Fever, nausea & vomiting Seen in diverticulitis due to ongoing infection [1]. Important : Persistent fever despite appropriate course of antibiotics should raise the possibility of abscess formation, which is caused by the inability of the pericolic tissues to suppress the inflammation [1]
Dysuria / frequency Seen in diverticulitis mimicking cystitis. The symptoms are caused by the irritation of the bladder by the adjacent inflammed bowel [1].
Bleeding per rectum Rarely seen in diverticulitis. Massive, painless bleeding of acute onset is seen in diverticular hemorrhage which is the most common cause of major lower gastro-intestinal bleeding. The bleeding is thought to occur by the medial thinning of the vasa recta when crossing over the dome of the diverticulum . Not so commonly, bleeding may be the initial presenting symptom of diverticular disease [1].
Faecaluria (passage of stools with urine) This occurs as a complication of diverticulitis when the peridiverticular abscess progresses to fistula formation. Colovesical fistula is the commonest type of fistula and seen more commonly in men than women as the uterus intervenes between the colon and the bladder [1].
Features of intestinal obstruction ( vomiting/ absolute constipation/ colicky abdominal pain) This is a rare complication of diverticular disease. The obstruction can occur due to adhesion formation after multiple episodes of diverticulitis, luminal narrowing caused by the inflammation or compression by the abscess. The small bowel is mostly affected [1]. Note: Only 15% of patients present with above symptoms as 85% of patients have asymptomatic diverticular disease. Thus diverticular disease is an incidental finding in the majority which is diagnosed by colonoscopy done for other conditions [1].
References
  1. SALZMAN H, LILLIE D. Diverticular disease: diagnosis and treatment. Am Fam Physician [online] 2005 Oct 1, 72(7):1229-34 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16225025
  2. PAINTER NS, BURKITT DP. Diverticular disease of the colon, a 20th century problem. Clin Gastroenterol [online] 1975 Jan, 4(1):3-21 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1109818
  3. SIMPSON J, SCHOLEFIELD JH, SPILLER RC. Pathogenesis of colonic diverticula. Br J Surg [online] 2002 May, 89(5):546-54 [viewed 28 August 2014] Available from: doi:10.1046/j.1365-2168.2002.02076.x
  4. CORTESINI C, PANTALONE D. Usefulness of colonic motility study in identifying patients at risk for complicated diverticular disease. Dis Colon Rectum [online] 1991 Apr, 34(4):339-42 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2007352
  5. FARRELL RJ, FARRELL JJ, MORRIN MM. Diverticular disease in the elderly. Gastroenterol Clin North Am [online] 2001 Jun, 30(2):475-96 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11432301

Examination

Fact Explanation
Tenderness in the left lower quadrant Symptomatic diverticular disease : Dysfunction of inhibitory neuromuscular control is thought to play a role in causing these clinical features [1]. Tenderness is in the left lower quadrant because the sigmoid colon is affected more. Sigmoid loop may be palpable on examination [2]. Diverticulitis : Tenderness is caused by the surrounding inflammation caused by the perforated diverticulum. The perforation is thought to occur by erosion of the luminal wall by raised intraluminal pressure or thickened faecal material pressing on the neck of the diverticulum. The tenderness is associated with guarding & rebound tenderness [2].
Reduced bowel sounds Seen in diverticulitis. Bowel sounds may be normal at the initial stage and can be increased in the presence of bowel obstruction caused by the inflammation [2].
Tender mass on palpation This should raise the suspicion of abscess formation which is a complication of diverticulitis [2].
Generalized abdominal tenderness with guarding & rigidity Occurs when peritonitis develops as a complication of diverticulitis due to the spreading of the infection [2].
References
  1. CAMILLERI M, LEE JS, VIRAMONTES B, BHARUCHA AE, TANGALOS EG. Insights into the pathophysiology and mechanisms of constipation, irritable bowel syndrome, and diverticulosis in older people. J Am Geriatr Soc [online] 2000 Sep, 48(9):1142-50 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10983917
  2. SALZMAN H, LILLIE D. Diverticular disease: diagnosis and treatment. Am Fam Physician [online] 2005 Oct 1, 72(7):1229-34 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16225025

Differential Diagnoses

Fact Explanation
Irritable bowel syndrome (IBS) IBS also causes abdominal pain [1].Both IBS and diverticular disease are thought to be caused by dysfunction of inhibitory neuromuscular control [2]. However, IBS is seen at much younger age than diverticular disease [1].
Cystitis As diverticulitis causes a ‘sympathetic cystitis’ by the irritation of the bladder by the inflammed bowel, symptoms similar to cystitis such as dysuria & frequency occur in the patient [3]. Urine full report and culture will help in excluding the diagnosis [4].
Colorectal malignancy As the diverticular disease occurs in the elderly population, the possibility of malignancy should be excluded by colonoscopy , as it also gives rise to change of bowel habits and bleeding per rectum [5].
Inflammatory bowel disease (IBD) IBD also causes abdominal pain, change of bowel habits and bleeding per rectum but extraintestinal features also occur unlike in diverticular disease [6].
Small bowel obstruction This also causes colicky abdominal pain and vomiting similar to diverticular disease but the onset of symptoms is acute. Imaging may help in excluding the diagnosis [7].
Acute appendicitis This also produces a colicky abdominal pain with/ without fever and tenderness on the right side. Ultrasound aids in making the diagnosis [8].
Ovarian torsion Can give rise to acute onset abdominal pain similar to diverticulitis. Presence of fever favor the diagnosis of diverticulitis and imaging will help in confirming the diagnosis [9].
Ovarian tumor /cyst Can cause abdominal pain and bloating with a palpable mass. Imaging can aid in excluding the diagnosis [9].
References
  1. WILKINS T, PEPITONE C, ALEX B, SCHADE RR. Diagnosis and management of IBS in adults. Am Fam Physician [online] 2012 Sep 1, 86(5):419-26 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22963061
  2. CAMILLERI M, LEE JS, VIRAMONTES B, BHARUCHA AE, TANGALOS EG. Insights into the pathophysiology and mechanisms of constipation, irritable bowel syndrome, and diverticulosis in older people. J Am Geriatr Soc [online] 2000 Sep, 48(9):1142-50 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10983917
  3. SALZMAN H, LILLIE D. Diverticular disease: diagnosis and treatment. Am Fam Physician [online] 2005 Oct 1, 72(7):1229-34 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16225025
  4. COLGAN R, WILLIAMS M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician [online] 2011 Oct 1, 84(7):771-6 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22010614
  5. RUDY DR, ZDON MJ. Update on colorectal cancer. Am Fam Physician [online] 2000 Mar 15, 61(6):1759-70, 1773-4 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10750881
  6. WILKINS T, JARVIS K, PATEL J. Diagnosis and management of Crohn's disease. Am Fam Physician [online] 2011 Dec 15, 84(12):1365-75 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22230271
  7. JACKSON PG, RAIJI MT. Evaluation and management of intestinal obstruction. Am Fam Physician [online] 2011 Jan 15, 83(2):159-65 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21243991
  8. HARDIN DM JR. Acute appendicitis: review and update. Am Fam Physician [online] 1999 Nov 1, 60(7):2027-34 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10569505
  9. GIVENS V, MITCHELL GE, HARRAWAY-SMITH C, REDDY A, MANESS DL. Diagnosis and management of adnexal masses. Am Fam Physician [online] 2009 Oct 15, 80(8):815-20 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19835343

Investigations - for Diagnosis

Fact Explanation
Computed tomography (CT) of abdomen Used to identify diverticula in symptomatic diverticular disease [1]. Note: Symptomatic diverticular disease is a diagnosis of exclusion made after excluding other differential diagnoses [1]. Contrast CT is the confirmatory investigation of diverticulitis, with the diagnostic feature being pericolic fat infiltration. Other features include thickened fascia, muscular hypertrophy & arrow-head sign (focal thickening of the colonic wall making the lumen arrow head shape with the point directed at the diverticulum) [2].
Full blood count High white cell count with predominant polymorphs is seen in diverticulitis due to ongoing infection [1].
Abdominal radiograph Needed to identify pneumo peritoneum in case of perforation. Other features are small & large bowel dilatation, ileus and evidence of bowel obstruction (air-fluid level/dilated bowel loops/valvular conniventis/ haustra) [1].
Ultrasonography of the abdomen Although this is rarely used, it has high specificity in confirming the diagnosis [3]. The investigation is mostly used when the clinical features are on the right side and when ovarian pathology is suspected [1].
Barium enema This is not much used now due to the risk of extravasation of contrast material in case of perforation. Water-soluble contrast should be used if the investigation is carried out and the findings include spasm, abscess, speculation of mucosa and perforation [1].
Angiography /nuclear bleeding scan/colonoscopy May be useful in diverticular hemorrhage [1].
References
  1. SALZMAN H, LILLIE D. Diverticular disease: diagnosis and treatment. Am Fam Physician [online] 2005 Oct 1, 72(7):1229-34 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16225025
  2. SHEN SH, CHEN JD, TIU CM, CHOU YH, CHANG CY, YU C. Colonic diverticulitis diagnosed by computed tomography in the ED. Am J Emerg Med [online] 2002 Oct, 20(6):551-7 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12369031
  3. CHOU YH, CHIOU HJ, TIU CM, CHEN JD, HSU CC, LEE CH, LUI WY, HUNG GS, YU C. Sonography of acute right side colonic diverticulitis. Am J Surg [online] 2001 Feb, 181(2):122-7 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11425051

Investigations - Followup

Fact Explanation
Colonoscopy This is necessary to rule out underlying bowel malignancy [1]. It is recommended to perform 6-8 weeks after a episode of acute diverticulitis [2].
CT colonography Can be useful to rule out malignancy [2].
References
  1. STOLLMAN NH, RASKIN JB. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol [online] 1999 Nov, 94(11):3110-21 [viewed 28 August 2014] Available from: doi:10.1111/j.1572-0241.1999.01501.x
  2. SALZMAN H, LILLIE D. Diverticular disease: diagnosis and treatment. Am Fam Physician [online] 2005 Oct 1, 72(7):1229-34 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16225025

Management - General Measures

Fact Explanation
Dietary modification A high-fiber diet is recommended in asymptomatic diverticulosis [1-6] and fiber supplementation in symptomatic diverticular disease [1]. It is recommended to refrain from eating nuts, corn, popcorn & seeds to prevent them entrapping in the diverticula, although this is not supported by scientific evidence [2].
Anti-spasmodic agents This is also not supported by scientific evidence despite the symptoms of bloating & cramping [3].
Hospitalization Should be considered in clinically unstable diverticulitis, elderly, in the presence of co-morbidities and occurrence of complications [2]. The patients should be managed with intravenous fluids and antibiotics with bowel rest [4].
Analgesia Mepiridine is the choice of analgesic as it reduced intra-luminal pressure as well [2]. Important: Morphine should be avoided as there is a risk of perforation as it increases intra-luminal pressure [3]. Non-steroidal anti-inflammatory drugs (NSAIDS) are also associated with increased risk of perforation [5] as well as glucocorticoids, hence must be used with caution [2].
References
  1. ALDOORI WH, GIOVANNUCCI EL, ROCKETT HR, SAMPSON L, RIMM EB, WILLETT WC. A prospective study of dietary fiber types and symptomatic diverticular disease in men. J Nutr [online] 1998 Apr, 128(4):714-9 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9521633
  2. SALZMAN H, LILLIE D. Diverticular disease: diagnosis and treatment. Am Fam Physician [online] 2005 Oct 1, 72(7):1229-34 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16225025
  3. REISMAN Y, ZIV Y, KRAVROVITC D, NEGRI M, WOLLOCH Y, HALEVY A. Diverticulitis: the effect of age and location on the course of disease. Int J Colorectal Dis [online] 1999 Nov, 14(4-5):250-4 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10647635
  4. STOLLMAN NH, RASKIN JB. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol [online] 1999 Nov, 94(11):3110-21 [viewed 28 August 2014] Available from: doi:10.1111/j.1572-0241.1999.01501.x
  5. GOH H, BOURNE R. Non-steroidal anti-inflammatory drugs and perforated diverticular disease: a case-control study. Ann R Coll Surg Engl [online] 2002 Mar, 84(2):93-6 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11995772

Management - Specific Treatments

Fact Explanation
Broad spectrum antibiotics with anaerobic & gram negative coverage Used in diverticulitis and the patient can be managed as an outdoor patient if the condition is stable. The common combinations are metronidazole & a quinolone/ metronidazole and trimethoprim-sulphamethoxazole/ amoxicillin-clavulonic acid [1]. A clear liquid diet should be followed for 48-72 hours with the slow initiation of diet if the symptoms are improving. Antibiotics should be given for 7 to 10 days [2]. Intravenous aminogycosides/monobactems/ cephalosporins are used in hospitalized patients, followed by 7 – 10 days course of oral antibiotics on discharge [2].
Surgery Although most recover from conservative therapy, those with recurrent attacks of diverticulitis and aggressive disease at young age may need surgery. The options available are resection with primary anastomosis, resection with colostomy & closure of rectal stump, transverse colostomy & drainage and laparoscopic colectomy [2].
Management of complications Absecess: CT guided percutaneous drainage is performed for small abscesses while surgery is required to drain large abscesses [2]. Fistula : Fistulectomy by surgery is the treatment of choice [2]. Bowel obstruction : Usually responds to conservative therapy and surgery may be required in non-responding patients [2]. Diverticular hemorrhage: Fluid resuscitation followed by medical management is the recommended treatment, with surgery considered for non-responding patients [1].
References
  1. STOLLMAN NH, RASKIN JB. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol [online] 1999 Nov, 94(11):3110-21 [viewed 28 August 2014] Available from: doi:10.1111/j.1572-0241.1999.01501.x
  2. SALZMAN H, LILLIE D. Diverticular disease: diagnosis and treatment. Am Fam Physician [online] 2005 Oct 1, 72(7):1229-34 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16225025