Diverticular disease

What is diverticular disease?

Diverticula are generally protrusions on the wall of a hollow organ. They often form on the intestinal mucosa in the large intestine. 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. However, diverticula can also affect other organs, such as the bladder or esophagus. They can take many different forms. They often resemble a balloon, a mushroom, a pear or a small bag. The following forms of the disease can be roughly distinguished:

• Diverticulosis: Diverticula form in many places in the intestine. However, the protrusions do not cause any discomfort and those affected do not feel them.
• Diverticular disease: The protrusions cause discomfort or complications.
• Diverticulitis: The protrusions become inflamed. This happens, for example, when a stool plug forms in the diverticulum entrance.

Diverticula – congenital or acquired?

Doctors also make a distinction as to whether the diverticula are congenital (true diverticula) or whether a person has acquired them in the course of life (false, fake or pseudo-diverticula). Colonic diverticula are acquired diverticula that develop where the intestinal wall is already weaker. This is the case at the sites where the blood vessels pass through.

Diverticular disease – frequency and age

Many people in western industrialized countries have diverticula in their bodies 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. The situation is different for older people over the age of 70: Around 50 percent of them have diverticula in their intestines. However, diverticula are more common in younger people. This is favored by sedentary activities and a lack of exercise.

Diverticula are less common in Asian and African countries, even in older people. Doctors suspect the reason for this lies in other eating habits.

Women and men are affected about equally often. Rarely (in about one percent), diverticulosis develops into diverticulitis within a few years – the protrusions then become inflamed. Diverticulitis can occur at any age.

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 promote diverticula:

• 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

Here too, the reasons why diverticula become inflamed and trigger diverticulitis are not yet entirely clear. Doctors suspect the following causes:

• 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.
• Severe kidney disease
• 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.

Diverticular disease often remains undetected

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 can be intense

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

• Sudden pain in the lower abdomen, which can be very severe and last longer. If the doctor presses on the abdomen, the abdominal muscles immediately tense up (so-called defensive tension). If he suddenly lets go, the pain intensifies.
• Mild fever
• Constipation, diarrhea
• Bloating
• Nausea, rarely vomiting

Diverticular disease and diverticulitis: diagnosis with us

At the beginning of the diagnosis, we will ask you about your medical history (anamnesis). The following questions are important, for example:

• What symptoms do you experience and since when?
• How intense are the complaints?
• Are there situations in which the symptoms improve or intensify? (After a bowel movement or meal)
• Have you ever been diagnosed with diverticula?
• Have you already had a colonoscopy?
• Do you have any known intestinal diseases or other illnesses?
• Are you taking any medications? If yes: Which and since when?
• What about your diet?

We also try to rule out other causes for the symptoms, for example appendicitis, irritable bowel syndrome or bowel cancer. The following tests are used in diagnostics:

• Physical examination: By palpating the abdomen, abnormalities can often be detected with your hands, and we can also listen to bowel sounds using a stethoscope.
• Palpation of the rectum with the finger (digital rectal examination, DRU)
• Measure body temperature
• Blood test: In the case of inflammation, the white blood cells, the C-reactive protein (CRP, a general inflammation marker) and the erythrocyte sedimentation rate are elevated.
• Urine test: If the inflammation has spread to the bladder, there will be an increase in white and red blood cells in the urine.
• Ultrasound examination (sonography). Ultrasound examination of the intestine shows very reliably whether diverticulitis is present. In most cases, it makes computer tomography superfluous.
• Possibly colonoscopy (not for acute diverticulitis!): We postpone it to a later date when the inflammation has largely healed. Because the intestinal wall is already sufficiently strained, the endoscope could injure the intestinal wall.

Sometimes computed tomography (CT) or magnetic resonance imaging (MRI) but always after the ultrasound.

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 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.

Diverticular disease – course and prognosis

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. Some measures that you can take yourself have a positive effect on diverticula. They may therefore also reduce the risk of developing diverticulitis. We must treat these in any case so that the inflammation does not spread throughout the body.