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Diverticulosis is a clinical condition in which multiple sac-like protrusions (diverticula) develop along the gastrointestinal tract. Though diverticula may form at weak points in the walls of either the small or large intestines, the majority occur in the large intestine (most commonly the sigmoid colon). The majority of individuals with diverticulosis are asymptomatic. Diverticular disease occurs when there is symptomatic diverticulosis (e.g., diverticular bleeding); diverticulitis (e.g., acute or chronic inflammation that may or may not is complicated by abscess formation, fistula formation, bowel obstruction, or perforation); or associated segmental colitis (e.g., inflammation in segments of the mucosal segments of the colon in between diverticula). This activity reviews the causes, pathophysiology, and diagnosis of diverticulosis and highlights the interprofessional team's role in managing these patients. Objectives: Review the causes of diverticulosis. Describe the workup of a patient with diverticulosis. Summarize the treatment options for diverticulosis. Explain the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by diverticulosis. Access free multiple choice questions on this topic.

Diverticulosis is a clinical condition in which multiple sac-like protrusions (diverticula) develop along the gastrointestinal tract. Though diverticula may form at weak points in the walls of either the small or large intestines, the majority occur in the large intestine (most commonly the sigmoid colon). The majority of individuals with diverticulosis are asymptomatic. Diverticular disease occurs when there is symptomatic diverticulosis (eg, diverticular bleeding); diverticulitis (eg, acute or chronic inflammation that may or may not is complicated by abscess formation, fistula formation, bowel obstruction, or perforation); or associated segmental colitis (eg, inflammation in segments of the mucosal segments of the colon in between diverticula).[1][2][3]

Diverticulosis is thought to result from abnormal peristalsis (eg, intestinal spasms), intestinal dyskinesia, or elevated segmental intraluminal pressures. Although the exact cause is unknown, some environmental and lifestyle risk factors have been linked to this condition.[4][5] Several studies have suggested that a low-fiber, high-red-meat diet may be associated with an increased risk of diverticulosis, although a high-fiber diet does not reduce symptoms of uncomplicated diverticular disease. In patients with symptomatic complicated diverticular disease (eg, inflammation or bleeding), a high-fiber diet may benefit by decreasing overall inflammation and favorably altering the intestinal microbiota. The risk of diverticulitis and bleeding is significantly higher in patients with obesity or larger waist circumference. Smokers have been noted to have an increased incidence of diverticular abscess formation or perforation. Medications associated with an increased risk of diverticular bleeding or diverticulitis include nonsteroidal anti-inflammatory drugs, opiates, and steroids.

The prevalence of diverticulosis is highest in the Western world and in countries with more Western lifestyles. Diverticulosis affects 5% to 45% of individuals in the Western world, depending on the diagnostic method and age. In general, the prevalence of diverticulosis increases with age, from under 20% of individuals affected at age 40 to 60% by age 60. Approximately 95% of patients in the Western world with diverticulosis have diverticula in the sigmoid colon. Of all patients with diverticulosis, 24% have diverticula involving mainly the sigmoid colon, 7% have diverticula evenly distributed throughout the colon, and 4% have diverticula located only proximal to the sigmoid colon.[6][7] In Asia, diverticulosis has a prevalence of approximately 13% to 25%. Individuals with diverticulosis in this region also tend to have predominantly right-sided colonic diverticula (unlike the Western world, where left-sided diverticula are much more common). Approximately 5% to 15% of patients with diverticulosis experience bleeding. A third of these patients experience massive bleeding. In 50% to 60% of patients with diverticular bleeding, the source is right-sided diverticula, possibly due to the thinner wall of the right colon or the wider necks and domes of right-sided diverticula (eg, increased surface area of vasa recta exposed to potential injury). Diverticulitis occurs in approximately 4% to 15% of patients with diverticula, and the incidence increases with age. On average, patients admitted for diverticulitis are about 63 years old. The overall incidence of diverticulitis continues to rise, with a 26% jump from 1998 to 2005, and the largest increases were observed in patients aged 18 to 44 years. Before age 50, diverticulosis is more common in males, whereas between ages 50 and 70, it is slightly more common in females. In those over 70, there is a significantly higher incidence of diverticulosis in females.

Diverticula occur in weaker portions of the colonic wall where the vasa recta infiltrate the circular muscular layer. The vast majority of colonic diverticula are “false” diverticula, in which the mucosa and submucosa herniate through a defect or weakness in the muscularis layer, and are covered externally only by serosa. True diverticula are much more uncommon (eg, the Meckel diverticulum) and involve outpouching of all layers of the intestinal wall (eg, mucosa, muscularis, and serosa).[8] A major predisposing factor for the formation of colonic diverticula is abnormal colonic motility (eg, intestinal spasms or dyskinesis), which results in exaggerated segmental muscle contractions, elevated intraluminal pressures, and the separation of the colonic lumen into chambers. As the sigmoid colon is the colon segment with the smallest diameter, it is also the segment with the highest intraluminal pressures. Connective tissue disorders such as Marfan syndrome, Ehlers-Danlos syndrome, or autosomal dominant polycystic kidney disease may also predispose an individual to colonic diverticula, as these diseases often involve structural changes (eg, weakness) in the intestinal wall. Diverticula are prone to bleeding due to the proximity of the vasa recta to the intestinal lumen, resulting from herniation of the mucosa and submucosa through the muscularis layer. With diverticula formation, the vasa recta become separated from the intestinal lumen by a single layer of mucosa and are therefore more susceptible to injury. This results in eccentric intimal thickening, medial thinning, and ultimately segmental weakness along these arteries, which predispose the vasa recta to rupture and bleeding into the intestinal lumen. Diverticular bleeding typically occurs in the absence of diverticular inflammation or infection (ie, diverticulitis).

Diverticula are prone to bleeding due to the proximity of the vasa recta to the intestinal lumen, resulting from herniation of the mucosa and submucosa through the muscularis layer. With diverticula formation, the vasa recta become separated from the intestinal lumen by a single layer of mucosa and are therefore more susceptible to injury. This results in eccentric intimal thickening, medial thinning, and ultimately segmental weakness along these arteries, which predispose the vasa recta to rupture and bleeding into the intestinal lumen. Diverticular bleeding typically occurs in the absence of diverticular inflammation or infection (ie, diverticulitis). Diverticulitis typically results from micro- or macroscopic perforation of a diverticulum, which may or may not be due to obstruction (eg, by a fecalith). Increased intraluminal pressures or inspissated (thickened and condensed) food matter, with resultant inflammation and focal necrosis, ultimately result in diverticular perforation. Associated inflammation is usually mild, and the pericolic fat and mesentery tend to wall off the perforations of the diverticula. This may or may not result in abscess, fistula, or intestinal obstruction formation. In rare cases, perforations may be large and uncontained, leading to peritonitis.

The mucosa of the diverticulum and the surrounding colon exhibit changes on histologic and tissue levels. Diverticular mucosa undergoes expansion of the lamina propria due to the accumulation of lymphoplasmacytic infiltrates. Histologic changes also include mucin depletion, the development of lymphoglandular complexes, and focal Paneth cell metaplasia. Acute inflammation is characterized by cryptitis and crypt abscesses. Hemorrhage may be seen within the diverticula and in the surrounding tissue. Scarring is evident in areas of resolved inflammation. In the mucosa surrounding the orifices of diverticula, we see additional changes, including pseudohypertrophy of the circular muscle, leading to exaggeration of mucosal folds and muscularization of the lamina propria; hyperplasia of the glands; and hemosiderin deposits in the submucosa. The features are usually indistinguishable from those of inflammatory bowel disease.

Most individuals with diverticulosis do not have any symptoms, and the condition itself is not dangerous. However, some patients may experience unexplained abdominal pain or cramping, alterations in bowel habits, or notice blood in the stool. Any bleeding associated with diverticulosis is painless. A diagnosis of diverticulosis is suspected when a patient presents with a history of painless rectal bleeding, unexplained abdominal pain or cramping, or alterations in bowel function. Acute diverticulitis (eg, inflammation, infection, or perforation) is typically suspected when a patient presents with lower abdominal pain (particularly on the left side). Patients may additionally present with abdominal tenderness to palpation and an elevated white blood cell count (leukocytosis). An abdominal computed tomography helps differentiate between complicated and uncomplicated disease in this case.

A diagnosis of diverticulosis is suspected based on clinical presentation (eg, a history of painless rectal bleeding or unexplained abdominal pain and cramping, altered bowel movements) and may be confirmed by colonoscopy or an X-ray following a barium enema. If the patient presents with extreme abdominal pain, however, the test of choice is typically a computed tomography of the abdomen to avoid the risk of intestinal rupture in the setting of intestinal infection or inflammation.[9] Colonoscopy in a prepped colon remains the best test to identify the source of bleeding if blood is present in the stool. If a colonoscopy is inconclusive, as with the acute or severe bleeding, angiography, computed tomography, or radionuclide scanning may be considered to locate the source. Patients presenting with acute diverticulitis may require additional treatment. Uncomplicated diverticulitis is treated non-operatively, with either intravenous or oral antibiotics. Complicated diverticulitis (eg, with an associated fistula, abscess, obstruction, or perforation) may, in addition to antibiotic therapy, require hospitalization and/or surgery to treat the associated complication.[10][11] Similarly, patients presenting with sepsis, immunosuppression, advanced age, significant comorbidities, high fever (greater than 39.2°C), significant leukocytosis, inability to tolerate oral intake, non-compliance, or failed outpatient treatment may require hospitalization for proper treatment.

Treatment typically aims to reduce intestinal spasms, which can be achieved by increasing dietary fiber and fluids. Greater intestinal bulk reduces the number of spasms and, as a result, decreases intestinal pressures. Studies found no positive or negative association between diverticular disease and consumption of nuts, grains, potassium, β-carotene, vitamin C, and magnesium. Data related to the association between diverticular disease and alcohol and red meat consumption is controversial. Most bleeding associated with diverticulosis is self-limiting and does not require intervention. Most bleeding associated with diverticulosis is self-limiting and does not require intervention. In cases of persistent bleeding, however, endoscopic, radiologic, or surgical management may be necessary to achieve hemostasis. Endoscopic approaches can include injection therapy, coagulation techniques such as cautery or argon plasma coagulation, and the use of mechanical devices, including clips, bands, or loops. The choice of intervention depends on the severity and location of the bleeding, as well as the patient’s overall condition. If a source cannot be determined in the case of recurrent bleeding, surgery may be considered to remove portions of the affected intestine (eg, colectomy). Similarly, in the case of a giant diverticulum, with an increased risk of infection and rupture, surgery is more likely to be considered.[4][12]

Diverticulosis presents with bleeding per rectum, and most of the time, that is the only presenting symptom. The differential diagnosis includes: Hemorrhoids Ulcers in the gut wall Inflammatory bowel disease Anal fissure Anal abscess or fistula Colonic polyps Colon cancer Constipation Radiation therapy Angiodysplasias Colitis Proctitis

Diverticula are usually seen on colonoscopy. Recent studies have shown that the detection rate of colonoscopy for left-sided diverticular disease is lower than that of barium enema. Follow-up barium enema for diverticular disease of the left colon is a potential area for study and improvement in clinical practice.

Diverticular disease is classified based on whether it is uncomplicated diverticulosis or has been complicated by diverticulitis. A summary is given below; Type 0: Asymptomatic diverticulosis Type I: Acute uncomplicated diverticulitis Type II: Acute complicated diverticulitis Type III: Chronic diverticular disease Complicated diverticular disease is further classified using the Hinchey classification system, which is largely based on computed tomography findings. Stage 1: Phlegmon (1a) or diverticulitis with pericolic or mesenteric abscess (1b) Stage 2: Diverticulitis with walled-off pelvic abscess Stage 3: Diverticulitis with generalized purulent peritonitis Stage 4: Diverticulitis with generalized fecal peritonitis

Diverticulosis is usually asymptomatic, or it may cause episodes of bleeding. Approximately 15% develop diverticular bleeding. If inflammation develops within the diverticula, around 85% of people respond to medical treatment. The remaining people may need surgery to repair the inflamed diverticula. Overall, the prognosis for most patients is good as long as they change their lifestyle, become physically active, eat a high fiber diet, and avoid constipation.

Diverticulosis usually remains asymptomatic or causes bleeding through the rectum. The symptomatic uncomplicated diverticular disease presents with constant abdominal pain attributed to diverticula in the absence of colitis or diverticulitis. Segmental colitis is the inflammation of the diverticular mucosa without the involvement of the diverticular orifices. Diverticulitis is defined as the inflammation of a diverticulum. It can be acute or chronic, uncomplicated, or complicated. Diverticulitis is complicated by an abscess, fistula, bowel obstruction, or free perforation. Inflammation within the diverticula may result in the formation of a fistula between the colon and adjacent viscera. Fistulas most commonly involve the bladder, resulting in a colovesical fistula, or the vagina, causing a colovaginal fistula. Colovesical fistula presents with pneumaturia, fecaluria, or dysuria. Patients with a colovaginal fistula may experience the vaginal passage of feces or flatus.

A diagnosis of diverticulosis often requires interdisciplinary care. Primary care doctors are front-line providers who see these patients. Gastroenterologists and general surgeons get involved if the diverticular disease gets complicated. Infectious disease helps determine which antibiotics would be appropriate for patients when the disease is refractory to standard regimens.

Diverticulosis refers to the presence of diverticula, pouch-like structures that can form at points of weakness in the colon's muscular wall. Diverticulosis usually affects men and women equally. People with diverticulosis who do not have symptoms do not require treatment. It is not a normal finding to see blood in the stool. This can be a sign of several conditions, some of which are serious and require immediate treatment. Anyone who experiences this should see their healthcare provider for an appropriate evaluation. Diverticular bleeding occurs when an artery within a diverticulum erodes, bleeding into the colon and causing painless rectal bleeding. Most clinicians recommend increasing fiber intake, which can help increase stool bulk. Fiber also helps control symptom recurrence. Patients with diverticular disease are also advised to avoid seeds, corn, and nuts because these foods are believed to increase the risk of diverticulitis. However, recent studies do not prove this association.

The prevalence of diverticulosis is very high, and while the disorder is asymptomatic, it can present with painless bleeding or progress into an inflammatory state. Because of the enormous healthcare costs in managing complications of diverticulosis, the condition is managed by an interprofessional team. A dietitian must be consulted to educate the patient on a high-fiber diet. The pharmacist should educate the patient on avoiding medications that cause constipation. The nurse should educate the patient on avoiding smoking, drinking plenty of water, and becoming more physically active, all of which reduce constipation. The clinician should educate the patient on the potential complications of diverticulosis and the associated healthcare costs. Once a patient has been diagnosed with diverticulosis, the interprofessional team should ensure the patient has sufficient knowledge to prevent complications. These simple recommendations can help prevent complications such as bleeding and diverticulitis. Finally, it is important to inform the patient that when surgery is undertaken for a complication of diverticulosis, there is always a risk of a stoma, which can seriously impair the quality of life.[13][14]