Diverticulitis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Cafer Zorkun, M.D., Ph.D. [2] Ahmed Elsaiey, MBBCH [3]
Overview
Diverticulitis is a common digestive disease particularly found in the colon (the large intestine).[1] Diverticulitis develops from diverticulosis, which involves the formation of pouches (diverticula) on the outside of the colon. Diverticulitis results if one of these diverticula becomes inflamed or infected.[2] The colon can become infected with craters of food stuck inside, which causes abdominal pain.
Historical Perspective
The diverticulum history itself goes back to 1700s when Dr. Lavater described the diverticulum and in 1812 Dr. Meckel gave a full description of it in 1700s, Dr. Littre was the first to describe the diverticular disease.
Classification
Diverticulitis may be classified according to the German guidelines which were recently (2014) passed by the German Societies of Gastroenterology (DGVS) and of Visceral Surgery (DGAV). They unanimously agreed on another classification (Classification of Diverticular Disease (CDD)), which takes practical algorithms (symptomatic, asymptomatic, complicated, uncomplicated, acute, recurrent), ongoing surgical aspects (purulent vs. fecal peritonitis), and contemporary diagnostic standards in clinical practice into account. As a result, this classification comprises the entire spectrum of diverticular disease.[3]
Pathophysiology
Diverticula is a protrusion of the intestinal layers consisting of mucosa and serosa. It occurs mainly on the left side more than the right side. Diverticulitis is the inflammation of this protrusion. It is believed that the first step in the pathogenesis of diverticulitis is the increase of intraluminal pressure, change of the intestinal motility and bacterial colonization. The inflammation is caused by histamine, tumor necrosis factor, and metalloproteinases which were found in diverticulitis patient's tissue biopsies. Obstruction of the diverticula leads to bacteria colonization which leads to inflammation in the end.
Causes
Common causes of diverticulitis include diverticulosis, a low-fiber diet, constipation, abdominal distension, and Meckel's diverticulum.
Differentiating diverticulitis from Other Diseases
It is important to differentiate sigmoid diverticulitis from a lot of inflammatory and non-inflammatory diseases of the gastrointestinal tract and the urogenital system. Differential diagnosis of diverticulitis can be based on the diseases causing lower abdominal pain and fever, and the diseases causing peritonitis. Diverticulitis can be differentiated from other diseases that cause lower abdominal pain and fever like appendicitis, inflammatory bowel disease, colon cancer, cystitis, and endometritis.
Epidemiology and Demographics
The prevalenceof diverticulitis is 20,000 individuals at age 40 and 60,000 at age 60. The greater incidence is in patients between 18 to 44 years. Men and women are equally affected by diverticulitis at age 50-70 years and men are more affected at age more than 70 years. The prevalence has increased in the developed countries. In the United States it has been around 312,000 cases admitted to the hospitals. In Japan, more cases of right side diverticulitis have been reported compared to the left side.[4][5]
Risk Factors
Risk factors in the development of diverticulitis include advanced age, chronic constipation, connective tissue diseases (such as Marfan syndrome or Ehlers Danlos syndrome), low dietary fiber intake, high intake of fat and red meat, and obesity. There are risk factors for the disease recurrence as well. These factors include multiple diverticula, intraperitoneal abscess, family history of diverticulitis, and a great portion of the colon involved in the disease.
Screening
There is insufficient evidence to recommend routine screening for diverticulitis.
Natural History, Complications, and Prognosis
Diverticulitis natural history is not well understood, but some studies showed a benign course if kept untreated. Diverticulitis can cause many complications that could be fatal in some cases. These complications include abscess, perforation, peritonitis and fistula formation. Prognosis of diverticulitis is excellent and conservative treatment is successful in 70 to 100 percent of patients.
Diagnosis
History and Symptoms
When taking a medical history, the doctor may ask about bowel habits, pain, other symptoms, diet, and medications. The physical exam usually involves a digital rectal exam. To perform this test, the doctor inserts a gloved, lubricated finger into the rectum to detect tenderness, blockage, or blood. The doctor may check stool for signs of bleeding and test blood for signs of infection.
Physical Examination
Diverticulitis diagnosis depends on taking a proper history and doing physical examination. The known diagnostic criteria for diverticulitis includes abdominal tenderness especially in the left lower quadrant, leukocytosis and CT scan findings helps in disease confirmation. Fever is common in diverticulitis patients. Abdominal examination will reveal tenderness, decreased bowel sounds and palpable mass may be felt. In some patients, genitourinary signs of cystitis would occur due to bladder irritation.[6]
Laboratory Findings
Diverticulitis diagnosis starts by taking history precisely and perform physical examination. Lab tests are important in excluding other causes of abdominal pain and any other gastrointestinal disease. These lab tests include CBC, CRP, urinalysis and liver tests. Imaging procedures are important measures in diagnosing diverticulitis including the CT scan and colonoscopy.[7][8]
CT scan
The CT scan is very sensitive (98%) in diagnosing diverticulitis. Using oral or intravenous contrast will have a good impact on the CT scan accuracy. It may also identify patients with more complicated diverticulitis, such as those with an associated abscess. CT also allows for radiologically guided drainage of associated abscesses, possibly sparing a patient from immediate surgical intervention. CT scan is not only important in the diagnosis of diverticulitis but also needed to exclude the cancer possibility in these patients.[9][10][11][12][13]
MRI
MRI is a good imaging modality that can be used in diagnosis of diverticulitis since it has an advantage that there is no exposure to radiation and it rules out other abdominal causes of acute abdomen. However, it is not the best diagnostic procedure to diagnose diverticulitis and CT scan is preferred more. MRI shows specific findings of diverticulitis which include thickening of the colon wall, presence of the diverticula, and exudates out of the colon. It may also shows presence of multiple abscesses.[14][15]
Ultrasound
Meckel's diverticula are usually seen as tubular incompressible blind ending hypoechoic structures with irregular margins. Occasionally it may also be seen as a cyst, raising a different differential diagnosis of intestinal duplication which however, is said to have a regular margin.
X ray
X ray is a supportive diagnostic modality to diverticulitis although it is not the best modality. It can be used in case the CT scan is not available and in the uncomplicated cases. The radiographies used are abdominal x ray, barium enema and chest x-ray. The barium enema has disadvantages, as it can cause rupture and peritonitis. Abdominal x-ray shows multiple air and fluid levels in case of intestinal perforation. Chest x-ray is important to be done in patients with diverticulitis to investigate for the pneumoperitoneum; which is a harbinger to a critical illness and will lead to change in the management plan in the case.
Other imaging findings
There are no other specific imaging findings for diverticulitis. Other studies, such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.
Other diagnostic studies
There are no other specific diagnostic studies for diverticulitis. Other studies, such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.
Treatment
Medical Therapy
An initial episode of acute diverticulitis is usually treated with conservative medical management, including bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy which covers anaerobic bacteria and gram-negative rods. Patients who have recurring acute attacks or who develop diverticulitis-associated complications, such as peritonitis, abscess, or fistula, require surgery, either immediately or on an elective basis.
Surgery
If symptoms of diverticulitis are frequent, or the patient does not respond to antibiotics and resting the colon, the doctor may advise surgery. The surgeon removes the affected part of the colon and joins the remaining sections. This type of surgery—called colon resection—aims to prevent complications and future diverticulitis. The doctor may also recommend surgery for complications such as a fistula or partial intestinal obstruction.
Immediate surgery may be necessary when the patient has other complications, such as perforation, a large abscess, peritonitis, complete intestinal obstruction, or severe bleeding. In these cases, two surgeries may be needed because it is not safe to rejoin the colon right away. During the first surgery, the surgeon cleans the infected abdominal cavity, removes the portion of the affected colon, and performs a temporary colostomy, creating an opening, or stoma, in the abdomen. The end of the colon is connected to the opening to allow normal eating, while healing occurs. Stool is collected in a pouch attached to the stoma. In the second surgery several months later, the surgeon rejoins the ends of the colon and closes the stoma.
Prevention
Primary prevention of diverticulitis follows the prevention of constipation by using osmotic agents like lactulose, polyethylene glycol or magnesium salts. High fiber diet should be given till constipation improves. Usage of laxatives and drinking plenty of fluids daily will be helpful.
References
- ↑ Diverticulosis and Diverticulitis. National Institute of Health - National Institute of Diabetes and Digestive and Kidney Diseases (2016). https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/diverticulosis-diverticulitis/Pages/overview.aspx Accessed on July 28, 2016
- ↑ Diverticulitis entry at Merriam Webster's Medical dictionary
- ↑ DeJoy SQ, Ferguson KM, Sapp TM, Zabriskie JB, Oronsky AL, Kerwar SS (1989). "Streptococcal cell wall arthritis. Passive transfer of disease with a T cell line and crossreactivity of streptococcal cell wall antigens with Mycobacterium tuberculosis". J Exp Med. 170 (2): 369–82. PMC 2189401. PMID 2502600.
- ↑ Painter NS, Burkitt DP (1975). "Diverticular disease of the colon, a 20th century problem". Clin Gastroenterol. 4 (1): 3–21. PMID 1109818.
- ↑ Miura S, Kodaira S, Shatari T, Nishioka M, Hosoda Y, Hisa TK (2000). "Recent trends in diverticulosis of the right colon in Japan: retrospective review in a regional hospital". Dis Colon Rectum. 43 (10): 1383–9. PMID 11052515.
- ↑ Thompson WG, Patel DG (1986). "Clinical picture of diverticular disease of the colon". Clin Gastroenterol. 15 (4): 903–16. PMID 3536213.
- ↑ Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons (2006). "Practice parameters for sigmoid diverticulitis". Dis Colon Rectum. 49 (7): 939–44. doi:10.1007/s10350-006-0578-2. PMID 16741596.
- ↑ Käser SA, Fankhauser G, Glauser PM, Toia D, Maurer CA (2010). "Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis". World J Surg. 34 (11): 2717–22. doi:10.1007/s00268-010-0726-7. PMID 20645093.
- ↑ Schreyer AG, Layer G, German Society of Digestive and Metabolic Diseases (DGVS) as well as the German Society of General and Visceral Surgery (DGAV) in collaboration with the German Radiology Society (DRG) (2015). "S2k Guidlines for Diverticular Disease and Diverticulitis: Diagnosis, Classification, and Therapy for the Radiologist". Rofo. 187 (8): 676–84. doi:10.1055/s-0034-1399526. PMID 26019048.
- ↑ Neff CC, vanSonnenberg E (1989). "CT of diverticulitis. Diagnosis and treatment". Radiol Clin North Am. 27 (4): 743–52. PMID 2657852.
- ↑ Ambrosetti P (2016). "Acute left-sided colonic diverticulitis: clinical expressions, therapeutic insights, and role of computed tomography". Clin Exp Gastroenterol. 9: 249–57. doi:10.2147/CEG.S110428. PMC 4993273. PMID 27574459.
- ↑ Andeweg CS, Wegdam JA, Groenewoud J, van der Wilt GJ, van Goor H, Bleichrodt RP (2014). "Toward an evidence-based step-up approach in diagnosing diverticulitis". Scand J Gastroenterol. 49 (7): 775–84. doi:10.3109/00365521.2014.908475. PMID 24874087.
- ↑ Goh V, Halligan S, Taylor SA, Burling D, Bassett P, Bartram CI (2007). "Differentiation between diverticulitis and colorectal cancer: quantitative CT perfusion measurements versus morphologic criteria--initial experience". Radiology. 242 (2): 456–62. doi:10.1148/radiol.2422051670. PMID 17255417.
- ↑ Stollman NH, Raskin JB (1999). "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. 94 (11): 3110–21. doi:10.1111/j.1572-0241.1999.01501.x. PMID 10566700.
- ↑ McKee RF, Deignan RW, Krukowski ZH (1993). "Radiological investigation in acute diverticulitis". Br J Surg. 80 (5): 560–5. PMID 8518890.