Chapter 85

Diverticular disease is a common GI disorder with a spectrum of conditions ranging from asymptomatic diverticulosis to life-threatening diverticulitis. Diverticula are small herniations through the wall of the colon. Diverticulitis develops when diverticula become inflamed or infected.

Although uncommon in developing countries, diverticular disease has become increasingly prevalent in industrialized nations. There are no population studies, but based on radiographic and autopsy analysis, it is estimated that the prevalence of diverticulosis is 2% to 5% in patients <40 years of age, 30% by age 60, and >70% by age 85.1,2 In most patients, diverticular disease is an incidental finding, and approximately 70% will remain asymptomatic. Diverticular bleeding occurs in 5% to 15% of patients,3 and 15% to 25% of patients will develop diverticulitis.2 Diverticulitis accounts for 130,000 hospitalizations annually in the U.S.4

The development of diverticulosis is thought to be due to increased intraluminal pressures in the colon and weakening of the bowel wall. Western dietary factors, such as low fiber, high fat, and high refined carbohydrates, seem to promote decreased GI transit times, which may lead to high intraluminal colonic pressures and, thus, diverticula.5,6 Acquired diverticular disease is also more common in those with sedentary lifestyles7 and in obese patients. In one large prospective cohort study of male health professionals, central obesity significantly increased the rate of diverticulitis, complications from diverticulitis, and diverticular bleeding.8 Diverticular disease has also been linked to smoking, alcohol, caffeine, and the ingestion of seeds and nuts, but none of these factors have substantial evidence to support a causal relationship.

In the U.S., diverticular disease is almost exclusively a left-sided colon disease, specifically the sigmoid colon. Right-sided disease accounts for only 2% to 5% of cases. In Asian societies, diverticular disease is predominantly right-sided.9

Diverticula are small herniations at sites where the vasculature, called vasa recta, penetrate the circular muscle layer of the colon. Although true diverticula involve all layers of the colon wall, most acquired diverticula are considered false diverticula, involving only the mucosal and submucosal layers. Diverticula usually range from 5 to 10 mm, but can extend up to 20 mm in length. Diverticulitis is thought to be due to erosion of the diverticular wall by inspissated fecal material, resulting in inflammation and microperforation.10 The most common bacterial pathogens isolated are anaerobes, including Bacteroides, Peptostreptococcus, Clostridium, and Fusobacterium as well as gram-negative rods, such as Escherichia coli.

Classically, diverticulitis presents with left lower quadrant abdominal pain, fever, and leukocytosis. Patients with a redundant sigmoid colon, of Asian descent, or with right-sided disease may complain of right lower quadrant or suprapubic pain. The pain may be intermittent or constant and often associated with a change of bowel habits, either diarrhea (30%) or constipation (50%).11 Half of patients will describe a similar prior episode. Other associated symptoms include nausea/vomiting (60%), anorexia (40%), and urinary symptoms (10%).11 On physical ...

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