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Diverticulum (single) or diverticula (multiple) are outpouchings in the colonic wall. Diverticular disease is a spectrum of diseases:
- Asymptomatic diverticulosis: common incidental finding on routine colonoscopy
- Symptomatic diverticulosis: also known as symptomatic uncomplicated diverticular disease (SUDD); recurrent abdominal pain attributed to diverticulosis without colitis or diverticulitis (1)
- Acute diverticulitis: inflammation and/or infection
- Uncomplicated diverticulitis: left lower quadrant (LLQ) pain, tenderness, leukocytosis, but no peritoneal signs or systemic toxicity
- Complicated diverticulitis: secondary abscess formation, bowel obstruction or perforation, peritonitis, fistula, or stricture
- Diverticular bleeding
- Accounts for >40% of lower GI bleeds and 30% of cases of hematochezia in general
- Bleeding more common with right-sided diverticula
- System affected: entire GI tract except the rectum
- Diverticular disease accounts for ~300,000 hospitalizations per year in the United States.
- Diverticulitis occurs in 1–2% of the general population and in 4% of patients with diverticulosis over the course of their lifetime (1).
- Diverticular bleeding occurs in 3–5% of patients with diverticulosis.
- Prevalence of diverticulosis and the number of diverticula increase with age
- Diverticulosis occurs in 60% of the population >age 60 years and 70% by the age of 80 years.
- Increased from 62 to 75/100,000 persons from 1998 to 2005; large increase in incidence for patients <45 years of age, due to changes in diet
- Male = female overall; more common in men <65 years of age and more common in women >65 years
Etiology and Pathophysiology
A diverticulum forms where intestinal blood flow (vasa recta) penetrates the colonic mucosa. This results in decreased resistance to intraluminal pressure.
- Age-related degeneration of mucosal wall, increased intraluminal pressure from dense, fiber-depleted stools, and abnormal colonic motility contribute to diverticulosis.
- Most right-sided diverticula are true diverticula (all layers of the colonic wall).
- Most left-sided diverticula are pseudodiverticula (outpouchings of the mucosa and submucosa only).
- Diverticulitis occurs when local inflammation and infection contribute to tissue necrosis with risk for mucosal micro- or macroperforation.
- Diverticulitis: Microscopy reveals inflammation with lymphocytic infiltrate, ulceration, mucin depletion, necrosis, Paneth cell metaplasia, and cryptitis.
- Alterations in intestinal microbiota contribute to chronic inflammation (1,2).
- Thinning of the vasa recta over the neck of the diverticula increases susceptibility to bleeding.
- Diverticular disease and irritable bowel syndrome (IBS) may represent the same disease continuum.
- No known genetic pattern
- Asian and African populations have lower overall prevalence but develop diverticular disease with adoption of a Western lifestyle.
- Age >40 years
- Low-fiber diet
- Sedentary lifestyle, obesity
- Previous diverticulitis. Risk rises with the number of diverticula.
- Smoking increases the risk of perforation (1).
- Diverticular bleeding: increased risk with NSAIDs, steroids, and opiate analgesics. Calcium channel blockers and statins appear to be protective against diverticular bleeding.
- High-fiber diet or nonabsorbable fiber (psyllium)
- Vigorous physical activity
Commonly Associated Conditions
Colon cancer, connective tissue diseases, and inflammatory bowel disease