DIVERTICLES and DIVERTICULITIS: causes, symptoms and therapy of inflamed diverticulosis

THE diverticula they are small dilations of the intestinal wall, mainly affecting the colon and sigma. Most people with diverticular disease, better known as diverticulosis,  has few or no symptoms at all. In some cases, however, the symptoms are present and include symptoms such as abdominal pain, constipation or on the contrary diarrhea. When diverticulosis is associated with inflammation and infection it is called diverticulitis.

Diverticulitis is diverticulosis They can be diagnosed with radiological tests such as barium x-ray abdomen or abdominal CT scan, with or without contrast medium, or with endoscopic tests such as sigmoidoscopy and colonoscopy. However, the main examination with which diverticula are found is the colonoscopy, which offers a direct observation of diverticulosis.

The treatment of the diverticulosis may include a diet rich in fiber and adequate hydration. There care of the diverticulitis instead it requires antibiotic therapy, fasting and painkilling therapy. Foods from to eat that can prevent diverticulitis from worsening are fruits and vegetables, legumes and cereals, preferably whole grains.

It has been suggested that people with diverticulitis should avoid or at least limit their intake of seeds, nuts and corn, which can settle and settle in the diverticulum, increasing the chance of it becoming infected; however, there is little evidence to support this recommendation.  The complications of diverticulosis and diverticulitis include rectal bleeding, abdominal infections and colonic obstruction.

Diverticula and diverticulosis

What are the diverticula and where are they formed? The diverticulum it is nothing more than a saccular dilation of the wall of a hollow organ, in this case of the intestine, especially in the colon and the rectum-sigma.

The colon is a long tubular structure whose purpose is to eliminate waste materials left in the small intestine after digestion. Pressure within the colon is thought to cause pockets of tissue to protrude from the colon walls of the colon, especially in adults or elderly people. The diverticulum therefore it is a small bag that protrudes externally with respect to the lumen of the hollow organ in which it is located.

Diverticula: the causes

As Yes form the diverticula? Why do they come the diverticula? There muscle wall of the colon it becomes thicker with increasing age, although the cause of this thickening is not entirely clear. It may depend on the pressure that the colon uses for remove the feces, which increases in conditions of incorrect nutrition and hydration.

One of the main ones causes for the onset of diverticula it is undoubtedly the pressure in the intestinal lumen. Some situations in fact, such as one diet to low content of fiber (diet poor of slag) can lead to the formation of dry stools is hard and that require more force to be ejected.

Diverticula and diverticulosis

The large intestine, commonly called the colon, with typical diverticula in the descending part.

The pressure inside the colon can consequently become high and over time, it can help push the intestinal wall outwards through areas of least resistance in the muscle wall, by the same principle that leads to the formation of hernias or laparoceli. These "pouches" or "bubbles" that develop are called diverticula.

The lack of fiber in the diet was considered the most likely cause of the diverticulosis and there is also a good correlation in countries around the world between the amount of fiber consumed in the diet and the presence of this pathology. However, studies are still not convincing in determining that the low-fiber diet is causing this type of problem.

Many people with diverticular disease have excessive thickening of the muscle wall of the colon where diverticula form. The muscle contracts more and more strongly and these abnormalities of the muscular layer may be among the contributing factors to the formation of diverticulitis.

There may also be diverticula in other parts of the body, such as the Zenker's diverticulum, which can be found at the transition between pharynx and esophagus. In this article, however, we will refer to intestinal diverticula, which represent the vast majority of all diverticula and which are referred to by the term diverticulosis.

Diverticula can form throughout the colon but typically emerge in the left colon, the descending colon (diverticulosis of the colon), especially near its terminal part, also called the sigmoid colon or sigma (diverticulosis of the sigma), and they seem to be more widespread in Western countries. In Asian countries, diverticula form mostly on the right side of the colon, the ascending colon.

Diverticula are quite common in the Western world and tend to increase with age. They are quite rare before the age of 40, but they are present, it is estimated, in over 60% in people over the age of 75 in Italy. 

Diverticula: the symptoms

A person suffering from diverticula typically has few symptoms or even does not experience any symptoms. Diverticulosis in these individuals is typically found incidentally during tests and examinations for other intestinal problems. THE symptoms most common associated with diverticulosis I'm:

  • modest abdominal pain
  • constipation
  • diarrhea
  • meteorism
  • flatulence

In some patients the symptoms may be due to the simultaneous presence of the so-called syndrome ofirritable bowel (also called the irritable colon) or abnormalities in the function of the sigmoid muscles (in which case it is referred to as diverticular disease)

Occasionally, the diverticula can leak blood and this condition is called diverticular bleeding. However, this occurs more in case of diverticulitis with inflammation of the diverticula with an increased risk of rupture of the blood vessels inside them.

Diverticulitis

What is the acute diverticulitis? When a diverticulum or the material it contains becomes inflamed, a condition called diverticulitis.  An individual with diverticulitis often has abdominal pain, or constipation diarrhea, fever, and a high number of white blood cells in the blood. 

Diverticulitis

The difference between a simple diverticulosis, i.e. the presence of diverticula in the intestinal lumen, and diverticulitis, i.e. the inflammation of the same, with possible complications such as bleeding or diverticular rupture.

Causes of diverticulitis

Why do diverticula become inflamed? The main cause of diverticulitis is undoubtedly theinflammation which develops following theinfection of the material contained in one or more diverticula. This is why people with diverticula are usually advised to eat a diet free of seeds and other particles that could accumulate in the diverticular lumen, increasing the risk of becoming inflamed and infected (as will be explained later, recent scientific evidence have completely dispelled the myth of the diet without seeds and nuts).

Causes secondary of diverticulitis they can also be an irregular intestinal transit or an alteration of the intestinal bacterial flora in a pro-inflammatory sense.

Symptoms of diverticulitis

What are the symptoms of the diverticulitis? It has been hypothesized that 5% to 20% of individuals with diverticulosis will develop symptoms related to diverticulitis. The most common signs is symptoms of the diverticulitis I'm:

    • Abdominal pain (abdominal colic)
    • Abdominal tension and bloating
    • Abdominal burning
    • Back pain, often related to dorsal irradiation of pain in the abdomen
    • Fever with shivering
    • Asthenia and fatigue
    • Nausea and vomit
    • High white blood cells (leukocytosis)
    • High neutrophil granulocytes in the blood (neutrophilia)
  • Mild to severe constipation (intestinal sub-occlusion)
  • Diarrhea, sometimes with liquid or mucous stools

What to eat in case of diverticula?

Once formed, diverticulitis is permanent, since resorption of the diverticula is not possible. As for the prevention, no treatment was found to help prevent diverticular disease. However, there are recommendations regarding foods to eat and foods to avoid.

According to a well-known theory, the reduction of fiber consumption in diet it could cause diverticulosis, and therefore high-fiber diets are the most recommended treatment for primary and secondary prevention of the disease. 

Fiber can help increase stool mass, making it less hard, thus preventing constipation, and if it reduces pressure on the colon, it can theoretically help prevent further diverticula from forming or worsening the diverticular condition. What is the diet for diverticulosis recommended by nutrition experts? One of the cornerstones of diet in presence of diverticula is undoubtedly the intake of foods rich in fiber.

The foods high in fiber are mainly:

    • Fruits and vegetables
    • Beans (such as cannellini beans and borlotti beans)
    • Legumes (chickpeas, broad beans, peas, soybeans)
  • Cereals (corn, wheat, rice, barley, quinoa, oats, rye)

Foods to avoid in case of diverticula

The foods to be taken in moderation in case of diverticula are:

    • Popcorn
    • Poppy seeds
  • Sesame seeds
  • fruit with seeds such as kiwi, strawberries, pomegranates

Anyhow, recent studies have shown how the intake of foods containing small seeds or slags they do not appear to increase the risk of diverticulitis, and therefore are not to be avoided but probably only to be taken with caution.

There is evidence relating to the use of probiotics in diverticulitis? Since some scholars suggest a role of intestinal inflammation in the formation of diverticulaa, it has been hypothesized that colon bacteria may play a role in the formation, inflammation and eventual rupture of diverticula. However, there is insufficient evidence regarding the beneficial effect of lactic ferments for the treatment in patients with this pathology.

Intestinal well-being, as it is known, depends on many factors, including nutrition, hydration, lifestyle and physical activity, smoking, stress and daily and work habits. The health of the intestine therefore depends on a delicate balance between these multiple factors, and the same concept could apply to the prevention of intestinal diverticula formation.

Complications of diverticulitis

What are the complications more serious than diverticulitis? The most fearful complications of diverticulitis are:

    • Peritonitis: the rupture of one or more diverticula with intestinal material pouring into the peritoneum can lead to severe inflammation of the peritoneum
    • Abscess  abdominal: if a diverticulum is ruptured, the intestinal material that comes out of it can favor the formation of an abscess collection, especially in the perivisceral fat and in the excavation of the Douglas (anatomical cavity of the small pelvis)
    • Bowel obstruction, linked to the obstruction of the colon secondary to strong inflammation, or due to the paralysis of intestinal motility;
  • Diverticular bleeding: blood loss generated by the rupture of blood vessels contained in the diverticula, manifested by anemia, rettoraggia or melaena.
  • Sepsis and septic shock: dissemination of intestinal germs into the bloodstream, causing a systemic infection with complications also potentially fatal such as a sharp drop in blood pressure and blood perfusion of tissues.
  • Fistulas: inflammation can create abnormal communications with other organs, such as the genital (recto-vaginal fistulas) or urinary (bladder or ureteral fistulas).

Bleeding from diverticula can cause a reddish discoloration of the stool - rectorrhagia - in case of copious and violent bleeding, especially if coming from the lower intestinal tracts. The presence of blackish stools is instead motivated by the permanence of blood for a few hours in the intestinal lumen, synonymous with bleeding "distant" from the anal lumen, or bleeding that is not particularly copious - melena -. Bleeding can be continuous or intermittent, lasting up to several days.

Patients with constant bleeding are usually hospitalized for observation. They are given intravenous fluids to support their blood pressure. Blood transfusions are only needed for patients who have experienced severe blood loss. In an individual who has rapid and severe bleeding, blood pressure may drop, causing dizziness, shock, and loss of consciousness. 

In most patients, bleeding stops spontaneously. Patients with persistent and severe bleeding require surgical removal of the bleeding diverticula, although non-surgical treatments are first attempted to resolve the situation.

Diagnosis of diverticulosis and diverticulitis

How are diverticulitis and diverticulosis diagnosed? The simplest method for diagnosing diverticula is radiography ofabdomen to the barium, which allows the diverticula to be visualized as barium-filled bags protruding on the outside of the colon.

Direct visualization of the interior of the colon and the openings of the diverticula can be done by means of suitable flexible tubes (endoscopes) inserted through the rectum and then into the colon. Short tubes can be used (sigmoidoscopes) or longer tubes (colonoscopes) to aid in diagnosis and to rule out other diseases that may produce symptoms similar to that of diverticular disease.

There colonoscopy it is by far the main examination to diagnose the presence of intestinal diverticula, being the only one that allows you to view the intestine from the inside. But be careful: colonoscopy not is indicated in case of acute diverticulitis in place. In this case the diagnosis can be made through a combination of data such as blood tests, patient symptoms and a previous history of already known diverticula.

In patients in whom doubts persist, the diagnosis can be deepened through the CT scan of the abdomen, better if with a contrast agent (computed tomography or CT): this examination allows to detect specific signs such as the presence of inflammation of the tissues surrounding the diverticula, ruptured diverticula or abscess collections.

From the point of view of blood tests, we will often have:

  • High CRP
  • High ESR
  • High white blood cells
  • High neutrophils
  • Low hemoglobin

Diverticulosis and diverticulitis therapy

What is the therapy for adequate to cure diverticulitis? The lighter episodes of diverticulitis can be treated at home with the rest to bed, fasting and abundant hydration, therapy antibiotic, pain control medications (painkillers), nausea / vomiting (antiemetics) and intestinal colic (antispasmodics). In case of severe fever, abdominal pain and tension, the attending physician may consider a short hospitalization to perform intravenous antibiotic and rehydration therapy, more effective and safe for the therapy of the diverticulitis.

Medicines in diverticulitis

Most patients with diverticulosis have minimal or no symptoms, and require no specific treatment. A diet supplemented with fiber is recommended to prevent constipation and possibly also to prevent further diverticula from forming.

Symptomatic therapy for the diverticulitis. Mild acute diverticulitis patients, with symptoms such as modest abdominal pain or cramps due to intestinal muscle spasm in the inflamed diverticula, may benefit from anti-spastic drugs such as:

    • scopolamine (Buscopan)
    • octatropine (Valpinax)
  • dicyclomine (Duspatal)
  • phloroglucine (Spasmex)

However, when an episode of moderate-severe acute diverticulitis occurs, antibiotics are required, to be taken intravenously in the most severe forms. Oral antibiotics are sufficient when symptoms are mild or moderate. Some examples of commonly prescribed antibiotics include:

    • rifaximin (Normix)
    • ciprofloxacin (Ciproxin)
    • metronidazole (Flagyl)
    • cefalexin (Ceporex)
  • doxycycline (Bassado)
  • amoxicillin / clavulanic acid (Augmentin)

What are the other recommended treatments for diverticulitis? First of all, a water diet is indicated, i.e. only based on liquid foods (eg water and sweetened tea) in order to leave the intestine to rest. In the most severe forms, absolute fasting and the start of intravenous rehydration therapy with physiological and glucose solution is necessary.

Surgical treatment is necessary in cases in which medical treatment is not sufficient to calm the inflammatory state and symptoms, as well as for patients who develop a state of persistent bowel obstruction, continuous diverticular bleeding or abscesses that do not respond to medical therapy with antibiotics.

Surgical treatment of diverticulitis

What is the surgical treatment for diverticulitis? If diverticulitis does not respond to medical and drug treatment, it becomes necessary to assess the need for surgery. Surgery usually involves the drainage of abscesses or other collections of pus, if present, as well as the removal surgery of the segment of the colon containing the diverticula, usually the descending colon or the sigma.

Even the surgical removal of the bleeding diverticula becomes mandatory for patients presenting with persistent bleeding unresponsive to medical and endoscopic therapy. In patients who need surgery to stop persistent bleeding beforeoperation It is important to determine exactly where the bleeding is to guide the surgeon, and this can be assessed either through a colonoscopy, or through aangio Abdominal CT, which highlights the blood vessels and can precisely isolate the leaking artery.

Sometimes the inflammation in diverticulitis can involve the adjacent urinary bladder, causing direct communication between the two organs (fistula) resulting in severe recurrent urinary infections and passing of gas and stool during urination. This complication also requires surgery.

Sometimes a surgical operation may be suggested for patients with frequent bouts of diverticulitis that lead to continuous antibiotic intake, continuous hospitalization with consequent loss of work days and a deterioration in quality of life. During surgery, the goal is to remove all or part of the colon containing the diverticula to prevent future episodes of diverticulitis.

For minor interventions, minimally invasive surgery can be used, which allows a reduction in hospitalization times and post-operative complications.

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