Etiology And Risk Factors
Factors associated with diverticulosis include alterations in colonic wall resistance, colonic motility, and dietary issues, such as lack of fiber, that contribute to increased intraluminal pressure and weakness of the bowel wall.1 Genetic susceptibility is an important component for the development of diverticular disease because monozygotic twins are twice as likely as dizygotic twins to develop diverticulosis.7 Aspirin and nonsteroidal anti-inflammatory drugs increase the risk of diverticulitis .8 Other risk factors for diverticulitis include increasing age, obesity, and lack of exercise.1
What Is Diverticulosis And Diverticulitis
Diverticulosis and diverticulitis are two conditions that occur in your large intestine . Together they are known as diverticular disease. Both share the common feature of diverticula. Diverticula are one or more pockets or bulges that form in the wall of your colon.
Diverticula are like expanded areas or bubbles that form when you fill the inner tube of a bike tire with too much air. The increase in pressure from too much air being pumped into the inner tube causes the bubble to form where the rubber is the weakest. Similarly, an increase in pressure inside the colon causes pockets or bulges to form in weakened areas of your colons walls.
Diverticula can range from pea-size to much larger. Although they can form anywhere in the inner lining of your colon, they are most commonly found in your lower left-side, in the S-shaped segment of your colon called the sigmoid colon.
When Is Surgery Necessary For Diverticulitis
If diverticulitis does not respond to medical treatment, surgery may be required. This usually consists of draining any collections of pus, and surgically removing the segment of the colon where the diverticula are located . Persistent bleeding diverticula require surgical removal. Surgery is also necessary in cases where the diverticula erode into other organs such as the adjacent bladder , causing severe recurrent urine infections and passage of gas during urination.
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Can Diverticular Disease Be Prevented
Diverticula are permanent once formed and can only be removed surgically. There is currently no treatment to prevent diverticular disease. However, diets high in fiber are recommended to increase stool bulk and prevent constipation, which reduces pressure in the colon and may help prevent more diverticula from forming, or worsening of the condition.
Diverticulitis Symptoms, Diet, Treatment
Treating Diverticulitis With Amoxicillin
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Outpatient diverticulitis treatment with amoxicillin-clavulanate was just as effective as treatment with a combination of metronidazole and a fluoroquinolone, a researcher told Healio Primary Care.
Data show that treatment with amoxicillin-clavulanate does not carry the same risks for adverse events associated with fluoroquinolones.
According to researchers, acute diverticulitis is responsible for $5.5 billion in health care expenditures each year. The condition is common 209 cases per 100,000 person-years in the United States.
The two most commonly prescribed antibiotic regimens for outpatient diverticulitis are a combination of metronidazole and a fluoroquinolone or amoxicillin-clavulanate only, said Anne Peery, MD, MSCR, assistant professor of medicine in the division of gastroenterology and hepatology at the University of North Carolina School of Medicine.
While both regimens are considered firstline therapy, they differ significantly in mechanisms of action and side effects, she said. This is the ideal comparative effectiveness study, particularly given the growing list of harms associated with fluoroquinolone use.
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Diverticulitis: Overview And Management
When a micro- or macroperforation develops in a diverticulum and releases intestinal bacteria , it is referred to as diverticulitis.2,4 Inflammation resulting from this perforation remains localized in most patients , while others develop complications .4 Diverticulitis develops in 10% to 25% of patients with diverticulosis its incidence increases the longer the existence of diverticulosis.5,6 Diagnosis is preferably made by abdominal CT scan with oral and IV contrast. The differential diagnosis includes appendicitis and cancer of the colon and ovaries. Diverticular disease is commonly found in industrialized or developed nations where low-fiber diets are prevalent and rarely in Asia and Africa, where high-fiber vegetable diets predominate.5
1. L¸hrs H, Melcher R. Special gastrointestinal problems of elderly patients. MMW Fortschr Med.2007 149:29-32.
2. Bharucha AE, Camilleri M. Common Large Intestinal Disorders. In: Hazzard WR, Blass JP, Halter JB, et al. Principles of Geriatric Medicine and Gerontology. 5th ed. New York, NY: McGraw-Hill, Inc. 2003:646-648.
3. Bryan ED. Abdominal pain in elderly persons. Emedicine.com. Available at: www.emedicine.com/EMERG/topic931.htm. Accessed February 15, 2008.
4. Beers MH, Porter RS, Jones TV, et al. The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, NJ: Merck Research Laboratories 2006:159-161.
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Antibiotics For Acute Uncomplicated Diverticulitis: Time For A Paradigm Change
For years, acute uncomplicated diverticulitis has been considered a relatively straightforward disease to treat. Patients typically present to the Emergency Department or their primary care provider with new onset abdominal pain, often in the left lower quadrant. After a presumptive clinical diagnosis is made, or with a confirmatory CT scan, even a fresh-faced July intern knows that the only real clinical management question is deciding on inpatient or outpatient treatment. If the patient can take liquids, has tolerable pain and a supportive home environment, we send them home with oral antibiotics. If not, we admit them for IV antibiotics, fluids and pain control. Either way, the prescription of antibiotics have always been a given in the management algorithm, a practice uniformly advocated in practice guidelines, book chapters and review articles.
In this months issue of Gastroenterology, the American Gastroenterological Association has made things a little more complicated for that intern, as well as for the ED provider, the PCP, and the potential GI consultant. New guidelines for the management of acute diverticulitis suggest that antibiotics be used selectively, rather than routinely, in patients with uncomplicated acute diverticulitis. The guidelines are accompanied by a detailed technical review.
How To Prevent Diverticulitis From Recurring
Diverticulitis can be painful and scary, and may require a hospital stay, but with antibiotics, pain medications, and sometimes surgery, the colon can heal.
Diverticulitis still may recur, but there are plenty of ways to stop this from happening:
Move it. Find activities that you enjoy and get moving. The Centers for Disease Control and Prevention advises adults to get 150 minutes of moderate-intensity exercise per week, or 75 minutes of vigorous-intensity aerobic activity per week.
Fuel up with fiber. After your body has healed from diverticulitis, reach for fiber-rich fruits and vegetables to help prevent the disease from recurring.
Take a probiotic. These supplements can promote the growth of good bacteria in the gut, potentially helping to protect against diverticulitis.
Be wary of using just any supplement. When it comes to supplements, there are a number of ideas but unfortunately an insufficient amount of research to validate or invalidate the ideas, warns Bulsiewicz.
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Are Probiotics Helpful In Preventing Diverticulitis
Some researchers believe not having the proper balance of good bacteria in your gut may play a role in the development of diverticulitis. However, right now, theres not enough scientific evidence to prove that probiotics can help prevent diverticulitis. Probiotics may be helpful in preventing constipation however.
Treatments For Complicated Diverticulitis
While uncomplicated diverticulitis may require only a brief doctors visit, complicated diverticulitis is a completely different ball game, and treatment isnt as simple as a prescription and a few days on a liquid diet.
Complicated diverticulitis is defined by the presence of a more advanced disease, such as perforation, abscess, fistula, intestinal obstruction, or bleeding, Bulsiewicz says. Generally, those with complicated diverticulitis will be hospitalized and theres a much higher likelihood of requiring surgery to fix the issue, although not always.
Heres what you can expect treatment-wise if youre diagnosed with a more serious case of diverticulitis.
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What Are The Symptoms Of Diverticulosis
Usually diverticulosis does not cause any troublesome symptoms. However, some people report:
- Tenderness over the affected area.
- Mild abdominal cramps.
- Swelling or bloating.
- Constipation.
Keep in mind that having one or more of these symptoms doesnt mean you have diverticulosis. These symptoms are common symptoms of other gastrointestinal disorders such as irritable bowel syndrome, celiac disease, inflammatory bowel disease, appendicitis, gallstones and stomach ulcers.
Is It Gas Pain Or Something More Serious
It can take a few days for uncomplicated diverticulitis pain to improve. But this doesnt mean that you have to live in agony. Taking Tylenol as directed can take the edge off your pain and help you feel better.
Other pain relievers might be your preferred drugs of choice. But when it comes to diverticulitis, acetaminophen is your best bet. This is because Advil and aspirin can cause abdominal pain and make an already upset stomach feel worse.
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Medical Approach Of Uncomplicated Diverticulitis
Diverticulitis treatment has been modified throughout time. The prescription of antibiotics used to be the therapeutic foundation of it, but it could be avoided now in well-selected patients . The nonantibiotic treatment strategy was formulated more than a decade ago when diverticular physiopathology was reassessed. At first, it was known that diverticular occlusion, micro-perforation, and peritoneal infection were the origin of diverticulitis . Later, with the finding of TNF-a overexpression, it was concluded that inflammation plays a crucial role in diverticulitis development . Even more, patients with diverticular disease seem to have changed in the gastrointestinal flora, including the depletion of some fecal microbiota species that have anti-inflammatory properties . Subjects with diverticula seem to have more macrophages in the intestinal wall than their healthier counterparts, promoting inflammation rather than infection and therefore raising the question about the actual need for antibiotics for its treatment during an acute flare.
Under this hypothesis, anti-inflammatory medication has been suggested as a treatment for acute uncomplicated diverticulitis, spearing the use of antibiotics as long as complications are not present.
Two of the most important contributions regarding the avoidance of the use of antibiotics were made by the AVOD and DIABOLO randomized control trials , published in 2011 and 2016, respectively.
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What Triggers Diverticulitis Flare
Certain factors that make a person more likely to develop diverticulosis are:
- Aging: The odd of developing diverticulosis increases with age, and it affects almost everyone older than 80 years.
- Gender: Males are more prone to develop diverticulosis than females.
- Weight:Overweight or obesity increases the odds.
- Hereditary: It can be a result of inherited genes.
- Improper diet: A diet low in fiber and high in refined foods and animal fats may increase the risk.
- Lack of exercise: Decreased or no physical activity, or a sedentary lifestyle contributes to the risk.
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What Are The Causes Of Diverticulosis And Diverticulitis
Aging and heredity are primary factors in the development of diverticulosis and diverticulitis, but diet also plays a role. Eating a diet low in fiber and high in refined foods may increase the risk. Indeed, in Western societies, an estimated 10% of people over 40 eventually develop diverticulosis the figure reaches at least 50% in people over 60. Diverticulitis will occur in about 10%-25% of those with diverticulosis.
Though it hasn’t been proven, some researchers think that if you are often constipated and usually strain when you have a bowel movement, you may create enough pressure in the intestinal walls to weaken them and begin the development of diverticular pouches. Another school of thought is that not enough fiber in the diet is responsible. The lack of fiber leads to increased bowel wall strain to move stool through the colon. That then causes increased local pressures that lead to the formation of pouches at weak points in the colon wall. The increased pressure along with undigested food caught in these pouches can erode the diverticular wall, causing inflammation and possible bacterial infection, which can result in diverticulitis.
How Are Diverticulosis and Diverticulitis Diagnosed?
If you think you have either diverticulosis or diverticulitis, talk to your doctor. Your doctor can perform tests to diagnose the conditions including:
What Are The Treatments For Diverticulosis And Diverticulitis
Once you develop diverticula, they are there to stay unless you have them surgically removed, which is not usually done. You can minimize the chances of developing an infection by modifying your diet. If you have a mild case of diverticulosis, your doctor may have you eat a high-fiber diet to make sure the bowels move regularly and to reduce the odds of getting diverticulitis.
If you develop diverticulitis you need to see a doctor to make sure you recover completely and to avoid possible life-threatening complications. Diverticulitis is treated using diet modifications, antibiotics, and possibly surgery.
Mild diverticulitis infection may be treated with bed rest, stool softeners, a liquid diet, antibiotics to fight the infection, and possibly antispasmodic drugs.
However, if you have had a perforation or develop a more severe infection, you will probably be hospitalized so you can receive intravenous antibiotics. You may also be fed intravenously to give the colon time to recuperate. In addition, your doctor may want to drain infected abscesses and give the intestinal tract a rest by performing a temporary colostomy. A colostomy creates an opening so your intestine will empty into a bag that is attached to the front of the abdomen. Depending on the success of recovery, this procedure may be reversed during a second operation.
During acute attacks of diverticulitis, stick to clear liquids or broths while diverticula are inflamed and sensitive.
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Understanding What Diverticulitis Is And The Factors That May Cause It
To understand diverticulitis, you must first understand whats going on inside your colon not the most comforting thought, but a necessary one.
Sometimes for reasons not exactly understood small pouches or sac-like protrusions, called diverticula, develop in the colon , most often in the lower part.
One theory behind why these pouches form is straining from constipation. But because diverticula may not cause symptoms, its possible to have one or more without knowing that is, of course, until one of these sacs tears and becomes inflamed or infected.
Diverticulitis means that a sac-like protrusion has become inflamed and generally infected. In other words, diverticulitis means inflamed diverticulosis, explains Will Bulsiewicz, MD, a gastroenterologist and gut health expert in Mount Pleasant, South Carolina. People who develop diverticulitis will have pain in the left lower abdomen, and many will also have nausea with vomiting, fever and a change in bowel habits.
While this condition can affect anyone, the risk is higher if youre older, overweight, eat a low-fiber diet, smoke, dont exercise, or take steroids, opioids, or over-the-counter pain medications like ibuprofen and naproxen.
How Is Diverticulitis Treated
If your diverticulitis is mild, your healthcare provider will prescribe an oral antibiotic, such as metronidazole , trimethoprim-sulfamethoxazole , ciprofloxacin or amoxicillin and clavulanic acid . Rest, taking over-the-counter medications for pain and following a low-fiber diet or a liquid diet may be recommended until your symptoms improve. Once your symptoms improve, you can slowly return to soft foods, then a more normal diet, which should be one that includes many high-fiber foods. You and your healthcare provider will discuss the specifics of your treatment plan.
If your diverticulitis is severe, you have rectal bleeding or are having a repeat bout of diverticulitis, you may be admitted to the hospital to receive intravenous antibiotics, IV fluids or possibly be considered for surgery.
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What Kind Of Antibiotics Are Used For Diverticulosis
Diverticulosis is the disease process that occurs in the large intestine when a diveriticulum–a small bulging sack protruding from the large intestinal wall–becomes ruptured. You may begin to feel pain in the abdomen. You can have diverticuloisis and not realize it until the abdominal pain increases, and you may get a fever and abdominal tenderness. The problem tends to be more pronounced in people older than 60. Problems such as constipation, cramps and colonic obstruction may occur. It is treated with antibiotics.
If you are experiencing serious medical symptoms, seek emergency treatment immediately.
How Is Diverticulosis Treated
If you have diverticulosis, you likely dont have symptoms and dont need treatment. However, since diverticulosis could lead to diverticulitis, you should eat a diet high in fiber as a preventive measure. This means eating more fruits, vegetables, grains, nuts, seeds, beans, legumes and less red meat.
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Can A Certain Diet Help Treat Diverticulitis
Diet can play a role in treating and preventing attacks. So to keep your bowels functioning properly, you may need to drink more fluids and add more fiber.
In one study, there was a 42 percent reduced risk of developing diverticulitis among high-fiber consumers compared to low-fiber consumers, says Bulsiewicz. On the flip side, red meat consumption is strongly associated with diverticulitis. In fact, those eating red meat once per day have 25 times the risk of developing diverticulitis compared with those who eat it once per week or less.
As far as foods to avoid, some people believe they must avoid nuts or seeds to prevent diverticulitis. Motola explains that contrary to popular belief, ingesting nuts, corn, popcorn, and presumably seeds is not associated with an increased risk of diverticular disease.
Bulsiewicz agrees. Having done thousands of colonoscopies, I can honestly say that Ive never seen anything inside the colon to suggest to me that nuts and seeds are clogging up diverticula, he says.
