Diverticula and diverticulitis

What are diverticula?

Diverticula are generally protrusions on the wall of a hollow organ. They form particularly often on the intestinal mucosa in the large intestine – so-called intestinal diverticula. A preferred location is the section of bowel above the rectum – the sigmoid colon. Diverticula often form in large numbers there because the sigmoid colon has a curved course and there is particularly high pressure inside. If the diverticula in the rectum become inflamed, this is also referred to as sigmoid diverticulitis.

Forms of diverticular disease

Diverticula can be associated with various conditions, which are differentiated according to their course and symptoms:

• Diverticulosis
  • In diverticulosis, diverticula form in many parts of the intestine.
  • These protrusions do not usually cause any symptoms, which is why those affected often do not notice them.
  • It is usually discovered by chance during a colonoscopy or other examinations.
• Diverticular disease
  • At this stage, the diverticula cause discomfort.
  • Typical symptoms can include abdominal pain, bloating or a change in bowel movements.
• Diverticulitis (inflammation of the diverticula)
  • In diverticulitis, one or more diverticula become inflamed.
  • The cause or triggering factors of diverticulitis are unknown and cannot be defined in individual cases
  • The inflammation can lead to severe abdominal pain, fever and, in complicated cases, to severe complications such as abscesses, fistulas or perforation of the intestine.
• Diverticular bleeding
  • As diverticula often develop in the area of a blood vessel in the colon, diverticula can bleed.
  • Diverticular bleeding leads to blood in the stool
  • This should definitely be clarified by means of acolonoscopy.

Diverticula can cause persistent or recurring symptoms, which is known as chronic diverticular disease.

Diverticula – frequency and age

Many people in western industrialized countries have diverticula of the colon without knowing it. The older a person is, the more frequently diverticula occur in the bowel. Only around 10 percent of people under the age of 50 have such protrusions in their intestines. In contrast, around 50 percent of people over the age of 70 have diverticula in their intestines. Women and men are affected about equally often.

Diverticular disease: causes and risk factors

The causes of diverticular disease are not yet fully understood. However, some risk factors are known that favor the development of diverticula. The protrusions mainly form in areas where the intestinal muscles are weaker and where there is high pressure. This applies above all to the sigmoid colon, a special section of the large intestine. It runs in a curved S-shape and is located directly in front of the rectum. Here the stool exerts very high pressure on the intestinal wall. The sigmoid colon is considered the “high pressure zone” of the intestine and protrusions can develop there.

The following factors can presumably favor intestinal particles:

• Hereditary susceptibility to diverticula in the intestine
• Weakened connective tissue
• Disorders of bowel movements
• Severe overweight
• Low-fiber diet: it promotes constipation and hard stools
• High consumption of red meat (pork, beef, lamb, game, goat)
• Smoking
• Lack of exercise
• Sedentary activities with increased abdominal pressure

However, the influence of lifestyle on the risk of diverticula has not yet been clearly scientifically proven. Presumably, however, the lifestyle is associated with the intestinal protrusions.

Diverticulitis: causes of inflammation

It is not always clear why diverticula become inflamed and trigger diverticulitis. The following causes are suspected:

• Reduced blood flow favors inflammation, especially if the entrance of the diverticulum itself is closed with stool.
• Weakened immune system, for example due to cancer or after an organ transplant.
• Taking certain medications over a long period of time: examples include certain painkillers (non-steroidal anti-inflammatory drugs, NSAIDs), anti-inflammatory drugs (corticoids, “cortisone”), acetylsalicylic acid (ASA) or opioids.

Diverticulosis symptoms

The majority of people with diverticula in the intestine do not notice the protrusions because they do not cause any symptoms. However, diverticular disease causes symptoms, for example:

• Abdominal pain in the left lower abdomen
• Bloating
• Feeling of fullness
• Constipation and diarrhea
• Sometimes diverticula can also bleed.

The symptoms are often only temporary and then subside. Sometimes, however, they persist for longer. The symptoms are often more pronounced after eating and improve again after a bowel movement.

If your doctor has diagnosed you with diverticulosis, it is advisable to eat a high-fiber diet and drink plenty of fluids. In this way, complaints and complications can be partially avoided.

Diverticulitis symptoms

If the diverticula in the intestine become inflamed, very severe symptoms can occur. These include, for example:

• Pain in the lower abdomen
• Fever, chills

Diverticular disease and diverticulitis: diagnosis with us

You will undergo a physical examination and a blood test to determine the inflammation parameters. Depending on the severity and secondary diagnoses, further diagnostics using computer tomography (CT) may be indicated. A distinction can be made here between uncomplicated and complicated (with abscess, perforation) diverticulitis attacks.

Diverticular disease: prevention, early detection, prognosis

You cannot prevent diverticula in the intestine with 100 percent certainty. Nevertheless, a diet rich in fiber and regular exercise can reduce the risk of diverticular disease. Sufficient fluid intake (1.5 to 2 liters per day), exercise and sport, quitting smoking and maintaining a normal body weight are also good for digestion and the intestines.

The early detection of diverticula plays a lesser role here compared to other diseases. This is because most people do not experience any symptoms when diverticula have formed in the bowel. You can live with the intestinal protrusions without any health problems. However, if diverticula are known, it is important to recognize a possible transition from diverticular disease to diverticulitis as early as possible.

Course and prognosis of diverticular disease

The course and prognosis of diverticular disease are generally favorable – this is especially true if you maintain a healthy lifestyle. Many of those affected can thus live a completely normal everyday life. This can also often prevent the development of diverticulitis.

In rare cases (around one percent of those affected), diverticular disease develops into diverticulitis. The protrusions in the intestine then become inflamed and bacteria can colonize there. Pus foci (abscesses) can also develop in the intestinal wall. Without treatment, the inflammation can spread to neighboring tissue and other organs, such as the small intestine or urinary bladder.

The most feared is the rupture of the diverticula. Then their contents, including bacteria and pus, pour into the abdominal cavity, which is life-threatening! We have to treat the peritonitis immediately.

If diverticulitis recurs more frequently, the intestinal wall can become scarred. This causes constrictions in the intestine and, in the worst case, leads to intestinal obstruction. Sometimes blood vessels are also affected by the inflammatory reactions, resulting in intestinal bleeding. The bleeding often stops on its own, but sometimes we have to intervene therapeutically.

Diverticular disease: treatment depending on the symptoms

If the diverticula in the intestine do not cause any unpleasant symptoms, treatment is not necessary. The treatment of diverticular disease always depends on whether and what symptoms it is causing.

Treatment methods at the USZ

The treatment of diverticular disease has changed significantly in recent years. At the USZ, we follow the latest recommendations of the specialist associations and can therefore often avoid unnecessary operations.

Uncomplicated diverticulitis

Depending on age, secondary diagnoses and general condition, it may include simple outpatient pain therapy without antibiotics or antibiotic therapy in tablet form.

Complicated diverticulitis

Severe inflammation requires inpatient treatment in hospital with antibiotic therapy via the veins or sometimes even emergency surgery in life-threatening situations where there is free perforation of the bowel with discharge of pus and stool into the abdominal cavity.

Recurrent diverticulitis

In the case of recurrent diverticulitis, which leads to a reduction in quality of life due to repeated antibiotic therapy, hospitalization or uncertainty regarding the time of the next inflammation, a planned elective sigmoid resection can be evaluated. The section of colon affected by diverticulitis is usually removed in a minimally invasive procedure and the two ends are sutured together again using anastomosis.

It is important that a colonoscopy is carried out approx. 6-8 weeks after the first episode of diverticulitis has subsided. In rare cases, an apparent bout of diverticulitis can hide colon cancer (colon carcinoma). Colon cancer can only be ruled out with certainty during a colonoscopy in the inflammation-free interval.