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Diverticular Disease

Basics

Description

  • Diverticulum = single colonic wall outpouching; Diverticula = multiple

  • Disease spectrum:

    • Asymptomatic diverticulosis

    • Symptomatic uncomplicated diverticular disease (SUDD)

    • Acute diverticulitis: uncomplicated (no peritonitis/systemic signs) or complicated
      (abscess, perforation, peritonitis, obstruction, fistula, stricture)

    • Diverticular bleeding: accounts for >40% of lower GI bleeds, typically painless hematochezia

Epidemiology

  • 300,000 hospitalizations/year in U.S.

  • Diverticulitis in 1–2% of general population; 4% of diverticulosis patients

  • Diverticular bleeding in 3–5% of diverticulosis cases

  • Age-linked:

    • 20% at age 40

    • 60% by 60

    • 70% by 80

  • Men <65, women >65 more affected

  • Rising incidence in <45 y/o due to diet changes

Etiology & Pathophysiology

  • Diverticula form at weak points in colon wall (vasa recta penetration)

  • Contributing factors:

    • Age-related wall degeneration

    • High intraluminal pressure from low-fiber stools

    • Abnormal colonic motility

  • Left-sided: pseudodiverticula
    Right-sided: true diverticula

  • Diverticulitis = local inflammation + infection → risk of perforation

  • Bleeding from thinning vasa recta

  • Diverticular disease may overlap with IBS

  • No specific genetic pattern, but lifestyle factors play a role

Risk Factors

  • Age >40, low-fiber diet, obesity, sedentary life

  • Prior diverticulitis, smoking (↑ risk of perforation)

  • NSAIDs, steroids, opioids: ↑ bleeding risk

  • CCBs and statins: protective

Prevention

  • High-fiber diet, psyllium

  • Physical activity

Associated Conditions

  • Colon cancer, IBS, obesity, IBD, connective tissue disorders

Diagnosis

History

Diverticulosis

  • 80–85% asymptomatic

  • LLQ dull, colicky pain, worsens with food/BM

  • +/- diarrhea or constipation

Acute Diverticulitis

  • LLQ pain, fever/chills, anorexia, nausea/vomiting

  • Dysuria if bladder involved

  • Pneumaturia/fecaluria → colovesical fistula

Diverticular Bleeding

  • Painless hematochezia or melena

  • More common on right side

Physical Exam

Diverticulosis

  • Usually normal exam, possible distension or heme+ stool

Diverticulitis

  • LLQ tenderness, hypoactive/high-pitched bowel sounds

  • Rebound, guarding, rigidity = perforation

  • Rectal tenderness or mass, +/- fistula signs

Differential Diagnosis

  • UTI, nephrolithiasis, IBS, IBD, carcinoma, impaction, ischemic colitis, appendicitis, ectopic pregnancy

Diagnostic Tests

Initial Workup

Diverticulosis

  • No labs or imaging needed

Diverticulitis

  • WBC: may be normal early, then ↑

  • ESR↑, Hb normal (unless bleeding), urinalysis: sterile pyuria possible

  • Abdominal X-ray: check for free air/obstruction

  • CT abdomen with contrast: gold standard (sensitivity 98%, specificity 99%)

  • US/MRI as alternatives

Bleeding

  • Check Hb, coagulation, endoscopy or angiography to localize source

Treatment

General Measures

Diverticulosis

  • Fiber >30g/day, psyllium

Uncomplicated Diverticulitis

  • Outpatient, +/- oral antibiotics

  • Hospitalization if: toxicity, sepsis, peritonitis, poor response

Complicated Diverticulitis

  • Hospitalization, bowel rest, IV antibiotics

  • Use Hinchey classification (I–IV)

  • Improvement in 2–3 days; Abx for 7–10 days

Bleeding

  • 80% stop spontaneously

Medications

Symptomatic Diverticulosis

  • Rifaximin 400 mg BID × 7d/month

  • Mesalamine 800 mg BID

Acute Diverticulitis

Outpatient:

  • Cipro + Metronidazole or

  • TMP/SMX + Metronidazole

Inpatient:

  • Piperacillin/tazobactam, ampicillin/sulbactam, or ertapenem

  • Penicillin-allergic: levofloxacin + metronidazole

  • Severe: imipenem, meropenem

Recurrent:

  • Consider mesalamine ± rifaximin, probiotics

Diverticular Bleeding

  • Vasopressin IA infusion

  • Avoid opiates during acute episodes

Second Line

  • Augmentin, moxifloxacin + metronidazole

  • IV ampicillin + metronidazole + quinolone/aminoglycoside if severe

Referral

  • Post-diverticulitis colonoscopy in 6–8 weeks

  • Surgery/infectious disease/critical care if complicated

Surgery

  • Emergent if peritonitis, perforation, obstruction

  • Hinchey I/II: IR-guided abscess drainage

  • Hinchey III/IV: likely surgery during same admission

  • Recurrent cases: elective colectomy individualized

Bleeding Interventions

  • Endoscopy: injection, cautery, clips

  • Angiography: unstable patients or massive bleeding

  • Surgery: if uncontrolled/recurrent

CAM

  • Probiotics: mixed evidence in preventing recurrence

Admission Criteria

  • Admit if:

    • Complicated disease

    • Immunocompromised, elderly

    • Severe leukocytosis, fever >39°C

    • Microperforation, severe pain, PO intolerance

Ongoing Care

Follow-up

  • Reassess at 2–3 days, then weekly

  • Repeat CT/Admission if worsening

Diet

  • NPO during acute phase, advance slowly

  • High-fiber diet post-recovery

  • Avoiding nuts/popcorn not necessary

Prognosis

  • Good with early diagnosis and therapy

  • 33% recurrence after 1st, 66% after 2nd

  • Rebleeding risk ~6%

Complications

  • Hemorrhage, perforation, peritonitis, obstruction, abscess

  • Fistulas: colovesical, colovaginal

References

  1. Tursi A, et al. Nat Rev Dis Primers. 2020

  2. Eckmann JD, et al. Curr Opin Gastroenterol. 2022

  3. Peery AF, et al. Gastroenterology. 2021

Codes

  • ICD-10:

    • K57.92 – Diverticulitis, no perforation/abscess/bleeding

    • K57.13 – Small intestine w/o perforation, with bleeding

    • K57.21 – Large intestine w/ perforation/abscess, with bleeding

Clinical Pearls

  • Common in elderly on low-fiber Western diet

  • Fiber helps, but restriction (nuts/popcorn) not necessary

  • No antibiotics needed in low-risk uncomplicated diverticulitis

  • Recurrent cases don’t always require surgery

  • Colonoscopy post-diverticulitis is crucial to rule out cancer

  • Diverticular disease = major cause of lower GI bleeding