I think the important thing is to understand there’s diverticulosis, which are the presence of little sack like protrusions in the bowel, in the large intestine, and if they get inflamed, this is then called diverticulitis. If you have diverticulosis, which about 50% of those over the age of 60 have, you may not feel any symptoms, you may not know you have it.
However, if you have diverticulitis, you’ll know because you have abdominal pain, you may have a low-grade temperature, nausea, vomiting, you’ll generally feel unwell and that’s the time to consult your doctor. So diverticulosis is simply the presence of these sack like protrusions in the large intestine through the colon, and 50% over the age of 60 will have them especially in the Western world, but we are seeing an increasing proportion of younger people with diverticulosis.
We’re not really sure what causes it. But we do think that a diet low in fibre somehow alters the colonic motility creating increased pressure within parts of the bowel such as the left side of the bowel, the sigmoid colon. With this increased pressure, there are weak parts of the colon wall, especially where the blood vessels come in, and you can get little pouches which protrudes to the outside of the lumen of the bowel wall. Interestingly, the Asians seem to have a far increased risk of right sided, that’s right, colonic diverticulosis, whereas in the West, we see left sided predominance.
We’re not really sure why that is that difference. So diverticulitis is the acute inflammation of the diverticular. These little sacks in the large intestine, and what causes the actual inflammation we’re not quite sure, but there are two theories. One is that of damage, perhaps due to hard stool or food residue at the neck of the diverticulum, the sack that leads to inflammation and maybe a micro perforation, little tear with collection of bacteria.
But the other thought is, and this is not mutually exclusive, is that there’s damage to the blood vessels at the neck of that sack, and some kind of reduction in the blood flow then leads to bacterial proliferation. And again, micro perforation leading to the clinical symptoms, which include abdominal pain, nausea, perhaps vomiting, and the low-grade temperature. So, it’s common sense really, when you’ve got an acute inflammation, you’re generally not feeling well, you may not have an appetite.
In an acute diverticulitis, when you really may need to see a doctor, you should immediately go to a low residue diet: clear liquids, broths, and that may be the treatment for a lot of people with acute uncomplicated diverticulitis. In the past, we used to hospitalise all these people and they were given intravenous antibiotics. And indeed, some may still need that. However, there are a lot of people with this acute, uncomplicated diverticulitis, that could be managed at home without antibiotics on a liquid diet for 72 hours with paracetamol to ease the pain and oftentimes they will not need further antibiotics.
There have been recent studies looking into different ways to manage acute diverticulitis, especially when uncomplicated, and we found that we’re reducing hospitalizations, and there’s absolutely no risk to doing that. But the important factor is that you see a doctor or go to the A&E because if you have complicated disease, you will need to be admitted and you will need intravenous antibiotics.
The important factor is that the symptoms of acute diverticulitis can mimic that of many other diseases such as irritable bowel syndrome or bowel cancer, and most people who have had an episode of acute diverticulitis will need a colonoscopy: a camera examination of the bowel eight weeks after their acute flare just to make sure there’s nothing else underlying. So the symptoms of diverticulitis can vary.
They do include lower abdominal pain, especially on the left side, but maybe anywhere. Low grade temperature, general malaise and can be associated with nausea, vomiting, reduced appetite, but also there are urinary symptoms. For instance, if there’s inflammation near the bladder, you might feel that you have a urinary tract infection or need to pass urine even more. If you’re worried about any of this, it’s important to seek medical advice because this may be a more significant disease process. If it is acute diverticulitis, you may be referred to accident and emergency. You may see your GP and he may manage you to depending on how he feels you are on your clinical examination.
But clinically you can diagnose it. Oftentimes if you’re in A&E, we will obtain the CT scan for imaging to actually see if there’s any complications of diverticulitis. Although complications are rare, less common, they include things like abscess formation, which is a localised piece of infection. You can get perforation, which is a tear in the lining of the bowel, you can get peritonitis, which is widespread inflammatory change, which can be life threatening.
Few percent of people can bleed but this is not common with acute diverticulitis, and chronically you may get changes also. So, it’s important that you seek advice. So acute diverticulitis, that’s when you acutely become unwell with inflammation of one of these sacks or diverticular. And you can have complicated or uncomplicated diverticulitis. If it’s uncomplicated, you may generally be feeling a bit under the weather. And we can treat that with 72 hours of a liquid diet with paracetamol to alleviate the temperature and the pain.
If however, there are complications; if the temperature is very high, or if you’re older and you have other diseases such as you’re taking steroids, you’re on chemotherapy, you have diabetes, then you’re likely to be admitted to the hospital. And again, it’ll be a liquid diet and perhaps some intravenous antibiotics so that we can get to the root of the infection much, much quicker.