Diverticulosis & Diverticulitis Victor Politi, M.D., FACP, FACEP Medical Director St. John’s University, School of Allied Health Physician Assistant Program

Diverticulosis & Diverticulosis & DiverticulitisDiverticulitis

Victor Politi, M.D., FACP, FACEPVictor Politi, M.D., FACP, FACEPMedical Director Medical Director St. John’s University, School of St. John’s University, School of Allied Health Allied Health Physician Assistant ProgramPhysician Assistant Program

Diverticulum – A diverticulum is a pouch or Diverticulum – A diverticulum is a pouch or a pocket-like opening in the bowel wall, a pocket-like opening in the bowel wall, usually in the colon. usually in the colon. The pouch is formed by the hernia of superficial The pouch is formed by the hernia of superficial

layers of the colon through the weak points in layers of the colon through the weak points in the bowel wall a small pouch in the colon that the bowel wall a small pouch in the colon that bulges outward through a weak spot bulges outward through a weak spot

The occurrence of a diverticulum is known The occurrence of a diverticulum is known as diverticulosisas diverticulosis

Normal Abnormal

When the pouches become infected or When the pouches become infected or inflamed, the condition is called inflamed, the condition is called diverticulitis. diverticulitis.

This happens in 10 to 25 percent of This happens in 10 to 25 percent of people with diverticulosis. people with diverticulosis.

Diverticulosis and diverticulitis are Diverticulosis and diverticulitis are also called also called diverticular diseasediverticular disease

Diverticulitis can occur anywhere in Diverticulitis can occur anywhere in the gastrointestinal tract the gastrointestinal tract most commonly observed in the colon. most commonly observed in the colon. Small bowel diverticulitis is far less Small bowel diverticulitis is far less

common than colonic diverticulitis. common than colonic diverticulitis. Asymptomatic diverticulosis is a Asymptomatic diverticulosis is a

common condition, but few patients common condition, but few patients with diverticula develop with diverticula develop symptomatic diverticulitis. symptomatic diverticulitis.

In about 25% of patients with painful In about 25% of patients with painful diverticular disease - develops in the diverticular disease - develops in the bowel wall through the diverticulum bowel wall through the diverticulum leading to infection and inflammation leading to infection and inflammation around the colon. around the colon.

This complication is known as This complication is known as diverticulitis. diverticulitis.

The infection usually stays localized, but The infection usually stays localized, but can spread into the abdomen causing can spread into the abdomen causing severe diverticulitis. severe diverticulitis.

Aging Aging causes changes in collagen structure- may causes changes in collagen structure- may

lead to weakening of the colonic wall.lead to weakening of the colonic wall. Colonic motility disordersColonic motility disorders Long term Corticosteroid or NSAID use Long term Corticosteroid or NSAID use Genetics Genetics

believed to play a role, Asian people tend to believed to play a role, Asian people tend to have a predominance of right-sided have a predominance of right-sided diverticula, while Western people tend to diverticula, while Western people tend to have left-sided diseasehave left-sided disease

Predisposing FactorsPredisposing Factors

DiverticulitisDiverticulitisSymptomsSymptoms

Most common symptom -abdominal painMost common symptom -abdominal pain Most common sign- tenderness around the Most common sign- tenderness around the

left side of the lower abdomenleft side of the lower abdomen

If infection is the cause, fever, nausea, If infection is the cause, fever, nausea, vomiting, chills, cramping, and constipation vomiting, chills, cramping, and constipation may occur as well. may occur as well.

The severity of symptoms depends on the The severity of symptoms depends on the extent of the infection and complications extent of the infection and complications

Diverticulitis Diverticulitis ComplicationsComplications

Diverticulitis can lead to Diverticulitis can lead to AbscessAbscess Diverticular Hemorrhage Diverticular Hemorrhage Intestinal fistulaIntestinal fistula Intestinal perforationIntestinal perforation Intestinal obstructionIntestinal obstruction Sepsis and septic shockSepsis and septic shock

Infection Infection Treated with antibiotics Treated with antibiotics usually clears up after a few days of usually clears up after a few days of

treatment treatment Rest the Gut Rest the Gut

Abscess - Abscess - An abscess is an infected area with pus An abscess is an infected area with pus

that may cause swelling and destroy that may cause swelling and destroy tissue tissue


Perforation-Perforation- Sometimes the infected diverticula may develop Sometimes the infected diverticula may develop

small holes (perforations) small holes (perforations) The perforations allow pus to leak out of the The perforations allow pus to leak out of the

colon into the abdominal area colon into the abdominal area If the abscess is small and remains in the colon, If the abscess is small and remains in the colon,

it may clear up after treatment with antibiotics. it may clear up after treatment with antibiotics. If the abscess does not clear up with antibiotics, If the abscess does not clear up with antibiotics,

it may require drainage (percutaneous catheter it may require drainage (percutaneous catheter drainage) drainage)

Sometimes surgery is needed to clean the Sometimes surgery is needed to clean the abscess and, if necessary, remove part of the abscess and, if necessary, remove part of the coloncolon


Peritonitis- Peritonitis- (an infection of the abdominal (an infection of the abdominal cavity) cavity) A large abscess can become a serious A large abscess can become a serious

problem if the infection leaks out and problem if the infection leaks out and contaminates areas outside the colon. contaminates areas outside the colon.

Infection that spreads into the abdominal Infection that spreads into the abdominal cavity is called peritonitis. cavity is called peritonitis.

Peritonitis requires immediate surgery to Peritonitis requires immediate surgery to clean the abdominal cavity and remove clean the abdominal cavity and remove the damaged part of the colon. the damaged part of the colon.

Without surgery, peritonitis can be fatal.Without surgery, peritonitis can be fatal.


Fistula- Fistula- Abnormal connection of tissue between two Abnormal connection of tissue between two

organs or between an organ and the skinorgans or between an organ and the skin When damaged tissues come into contact with When damaged tissues come into contact with

each other during infection, they sometimes stick each other during infection, they sometimes stick together. If they heal that way, a fistula formstogether. If they heal that way, a fistula forms

When diverticulitis-related infection spreads When diverticulitis-related infection spreads outside the colon, the colon's tissue may outside the colon, the colon's tissue may stick to nearby tissues. stick to nearby tissues. The organs usually involved are the bladder, The organs usually involved are the bladder,

small intestine, and skin.small intestine, and skin.


FistulaFistula The most common type of fistula occurs The most common type of fistula occurs

between the bladder and the colon. between the bladder and the colon. Colovesicular fistula (colon to urinary Colovesicular fistula (colon to urinary bladder). bladder).

This is observed almost exclusively in menThis is observed almost exclusively in men Also seen in women following hysterectomy Also seen in women following hysterectomy This type of fistula can result in a severe, long-This type of fistula can result in a severe, long-

lasting infection of the urinary tract. lasting infection of the urinary tract. Can be corrected with surgery to remove the fistula Can be corrected with surgery to remove the fistula

and the affected part of the colon and the affected part of the colon Colovaginal and colocutaneous fistulae are Colovaginal and colocutaneous fistulae are

much less common much less common


Intestinal Obstruction Intestinal Obstruction The scarring caused by infection may The scarring caused by infection may

cause partial or total blockage of the cause partial or total blockage of the large intestine. large intestine.

When this happens, the colon is unable When this happens, the colon is unable to move bowel contents normally. to move bowel contents normally.

If the obstruction totally blocks the If the obstruction totally blocks the intestine, emergency surgery is intestine, emergency surgery is necessarynecessary


History/PhysicalHistory/Physical The clinical presentation of The clinical presentation of

diverticulitis depends on: diverticulitis depends on: locationlocation severity of the underlying severity of the underlying

inflammatory processinflammatory process and on whether complications are and on whether complications are

present present

Imaging StudiesImaging Studies X-rays to make sure the colon has not X-rays to make sure the colon has not

perforatedperforated CT scan with contrast of the CT scan with contrast of the

abdomen/pelvis if the diagnosis is abdomen/pelvis if the diagnosis is unclearunclear

Flexible Sigmoidoscopy and Barium Flexible Sigmoidoscopy and Barium enema only after symptoms are enema only after symptoms are improved (if these tests are done too improved (if these tests are done too early, they can cause a colon early, they can cause a colon perforation)perforation)

CT scan of the abdomen is CT scan of the abdomen is considered the optimal method of considered the optimal method of investigation in patients suspected investigation in patients suspected of acute diverticulitis. of acute diverticulitis.

CT scan is also very helpful in CT scan is also very helpful in determining the extent of determining the extent of complications of the disease complications of the disease

Imaging StudiesImaging Studies

ProceduresProcedures

Endoscopy is not usually used in the Endoscopy is not usually used in the evaluation of acute episodes of evaluation of acute episodes of diverticulitis because of the diverticulitis because of the possibility of perforation and possibility of perforation and subsequent development of subsequent development of peritonitis peritonitis

Treatment of Treatment of diverticulitisdiverticulitis

Treatment for diverticulitis focuses on:Treatment for diverticulitis focuses on: clearing up the infection and inflammationclearing up the infection and inflammation resting the colon resting the colon (bed rest,liquid diet, pain (bed rest,liquid diet, pain

meds as needed)meds as needed) preventing or minimizing complications preventing or minimizing complications

An attack of diverticulitis without An attack of diverticulitis without complications may respond to antibiotics complications may respond to antibiotics within a few days if treated early.within a few days if treated early.

Hospitalization is required if:Hospitalization is required if: patients are unable to tolerate oral patients are unable to tolerate oral

hydrationhydration if outpatient therapy failsif outpatient therapy fails if notable fever and/or peritoneal signs if notable fever and/or peritoneal signs

developdevelop if pain is severe enough to require if pain is severe enough to require

narcotic analgesianarcotic analgesia or if patients have a chronic underlying or if patients have a chronic underlying

medical condition. medical condition.


Surgical treatment is usually Surgical treatment is usually necessary in only 20-30% of patients necessary in only 20-30% of patients with acute diverticulitis with acute diverticulitis


Administer nothing by mouth in Administer nothing by mouth in episodes of moderate-to-severe episodes of moderate-to-severe acute diverticulitis.acute diverticulitis.

In mild episodes, a clear liquid diet In mild episodes, a clear liquid diet is advised.is advised.

Long-term management includes a Long-term management includes a high-fiber, low-fat, and low-beef diet.high-fiber, low-fat, and low-beef diet.

Dietary ManagementDietary Management

Increasing the amount of fiber in the Increasing the amount of fiber in the diet may reduce symptoms of diet may reduce symptoms of diverticulosis and prevent diverticulosis and prevent complications such as diverticulitis. complications such as diverticulitis. Fiber keeps stool soft and lowers Fiber keeps stool soft and lowers

pressure inside the colon so that bowel pressure inside the colon so that bowel contents can move through easily. contents can move through easily.

The American Dietetic Association The American Dietetic Association recommends 20 to 35 grams of fiber recommends 20 to 35 grams of fiber each day. each day.


Fiber product –Fiber product – Citrucel or Metamucil once a day. Citrucel or Metamucil once a day.

These products are mixed with water These products are mixed with water and provide about 2 to 3.5 grams of and provide about 2 to 3.5 grams of fiber per tablespoon, mixed with 8 fiber per tablespoon, mixed with 8 ounces of water. ounces of water.


Diverticulosis is a very common, and Diverticulosis is a very common, and usually a very benign conditionusually a very benign condition

Complications occur only in a Complications occur only in a minority of patients, and most of minority of patients, and most of them get well with medical them get well with medical treatment alone without any need treatment alone without any need for surgery for surgery

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Diverticulosis & Diverticulitis Victor Politi, M.D., FACP, FACEP Medical Director St. John’s University, School of Allied Health Physician Assistant Program