Brief Explanation about Diverticular Disease

Abstract

Diverticula, sac-like protrusions in hollow organ walls appear throughout the gastrointestinal system, most commonly in the duodenum near the ampulla. They are classified as true (congenital, with all intestinal wall layers) and false diverticula (acquired, with a muscular layer defect). Duodenal diverticula are usually asymptomatic, found incidentally during endoscopies. Symptoms, when present, manifest as dyspeptic complaints. Radiographs show these diverticula as atypical gas balloons, while CT scans reveal them as mass-like structures. Complications are rare but can include obstruction, bleeding, perforation, and blind loop syndrome. Less than 5% require surgical intervention due to complications. Treatment typically involves endoscopic or surgical excision. The management of biliary and pancreatic complications remains debatable.

1. Introduction

Diverticular disease, a common gastrointestinal disorder, has been the subject of extensive research and clinical guidelines. The prevalence of diverticular disease has been increasing, particularly affecting older age groups [1, 2]. The pathogenesis of diverticular disease is multifactorial, with factors such as obesity being identified as increasing the risks of diverticulitis and diverticular bleeding [3]. Furthermore, changes in dietary habits, such as the introduction of roller milling of flour, have been associated with the increased prevalence of diverticular disease [4]. The management of diverticular disease has evolved over the years, with the introduction of novel treatment methods such as laparoscopic colectomy and endoscopic band ligation for colonic diverticular bleeding [5, 6]. Additionally, the development of endoscopic classifications, such as the Diverticular Inflammation and Complication Assessment (DICA), has provided a framework for the clinical assessment and prediction of outcomes in diverticular disease [7, 8, 9]. The introduction of such classifications has facilitated a better understanding of the disease and improved interobserver agreement among community endoscopists [9]. Despite these advancements, the place of elective sigmoidectomy for colonic diverticular disease is still debated in the literature, highlighting the ongoing need for further research and consensus in the management of this condition [10]. In conclusion, diverticular disease presents a complex and evolving clinical landscape, with ongoing efforts to refine its classification, diagnosis, and treatment strategies.

2. Epidemiology, etiology, pathology

Diverticular disease is a prevalent condition in Western society and is a leading cause of outpatient visits and hospitalizations [11]. The etiology of diverticular disease is thought to result from structural abnormalities of the colonic wall, disordered intestinal motility, deficiencies of dietary fiber, and complex interactions among colonic motility, diet, lifestyle, and genetic features [7, 12]. Epidemiological studies have attempted to characterize the association between diverticular disease and colorectal cancer, yielding inconsistent results [13]. Additionally, the presence of associated symptoms such as abdominal pain, bloating, diarrhea, and constipation in the absence of inflammation of peri-diverticular mucosa identifies symptomatic uncomplicated diverticular disease (SUDD) [14]. Furthermore, the characteristic pathologic features of Crohn’s disease, such as transmural inflammation, epithelioid cell granuloma, fissuring, or fistula formation, may be seen in complicated diverticular disease or diverticulitis [15].

The epidemiology of diverticular disease has been the subject of evolving insights, with increasing hospital admissions for complications of diverticular disease, particularly in the elderly and emergency admissions [16]. Moreover, the prevalence of colonic diverticula has been increasing in recent years, leading to an increase in opportunities to treat patients with colonic diverticular disease, including diverticular bleeding and diverticulitis [17]. In terms of the pathology of diverticular disease, it is considered to be a chronic illness, and recent literature addresses the emerging insights regarding its pathophysiology and management, providing current answers to common clinical questions [9]. Additionally, diverticular colitis, also known as segmental colitis associated with diverticulosis, is a colonic inflammatory disorder on the spectrum of inflammatory bowel disease (IBD) [18].

In conclusion, diverticular disease is a complex condition with multifactorial etiology and evolving epidemiological insights. The pathology of diverticular disease involves chronic illness and inflammatory disorders, with potential overlap with other conditions such as colorectal cancer and Crohn’s disease. Understanding the epidemiology, etiology, and pathology of diverticular disease is crucial for effective management and treatment strategies.

3. Diverticula types by organs

3.1 Duodenal diverticula

Acquired diverticula are most commonly seen in the duodenum and tend to be localized near the ampulla; these diverticula are known as periampullary, juxtapapillary, and perivateral diverticula. Approximately 75% of juxtapapillary diverticula originate from the medial wall of the duodenum [19].

The duodenum is the second most common site of diverticula after the colon. The prevalence of duodenal diverticula detected in upper GI tract examinations has been reported to vary between 0.16 and 6% [4, 19]. The prevalence of duodenal diverticula increases with age. It is rare under 40 years of age. The mean age at diagnosis varies between 56 and 76 years. Duodenal diverticula are twice more common in women.

3.1.1 Clinical findings

The majority of duodenal diverticula are asymptomatic and are detected incidental to endoscopic examination of the upper gastrointestinal tract [20]. Those who are symptomatic have dyspeptic complaints.

They appear as atypical gas balloons on direct radiographs. On CT, it may appear as a mass-like structure containing air, air fluid level, liquid contrast or debris between the duodenum and pancreas. Magnetic resonance cholangiopancreaticography is useful in showing the relationship of the diverticulum with biliary and pancreatic structures.

Complications associated with duodenal diverticulum include biliary or pancreatic duct obstruction leading to cholangitis or pancreatitis, hemorrhage, perforation, and rarely blind loop syndrome (19, 21). Surgery is considered in less than 5% due to complications [21].

3.1.2 Treatment

Most duodenal diverticula are asymptomatic. Symptomatic duodenal diverticula require endoscopic or surgical excision because recurrence and complications cause serious morbidity. Lateral duodenal diverticula are usually treated with diverticulectomy if they cause bleeding or obstruction. Complications associated with medial duodenal diverticula should be treated endoscopically and nonoperatively if possible [21]. In an emergency, bleeding from the medial duodenal diverticulum is treated with lateral duodenotomy and ligation of the diverticulum vessel. Perforation is treated with extensive drainage instead of complex surgery. Diverticulectomy in diverticula with biliary and pancreatic complications is controversial and not routinely recommended [22].

3.2 Small intestine diverticula

Diverticula in the jejunum are more common and larger than in the ileum. Small bowel diverticula are pseudo diverticula (containing mucosa and serosa) and are seen in older age groups [23, 24]. Diverticula are multiple and usually located in the mesenteric wall.

3.2.1 Clinical findings and diagnosis

Most of them are asymptomatic. Common symptoms include severe postprandial pain, dyspeptic complaints, nausea, vomiting, and diarrhea. Acute complications such as bleeding, perforation, and obstruction may occur [24]. Diverticulitis is triggered by obstruction of the diverticulum mouth and consequent bacterial growth. As a complication of diverticulitis, diverticulitis perforation with or without abscess may occur.

A good anamnesis followed by CT examination of the distal duodenum may lead to a diagnosis. Capsule endoscopy can be used for diagnosis although it is costly [23]. Enteroclysis is the most sensitive method to detect small intestinal diverticula. However, most small bowel diverticula are detected incidentally.

3.2.2 Treatment

Small bowel diverticula are mostly asymptomatic and do not require treatment. Segmental resection and anastomosis is recommended in diverticula that are symptomatic and cause complications such as bleeding, obstruction, and perforation. If peritonitis occurs after perforation, enterostomy is required since anastomosis after resection is risky. Antibiotics are frequently used in the treatment of patients with malabsorption due to bacterial proliferation and blind loop syndrome [25].

3.3 Meckel’s diverticula

It is a true diverticulum of the small intestine. It is the most common congenital anomaly of the gastrointestinal tract and may remain silent for life. It occurs in approximately 2% of the population [26]. It is located within 100 cm proximal to the ileocecal valve (Figure 1). It usually contains heterotropic mucosa. The most common mucosa is gastric, followed by pancreatic acini [26]. There is the famous rule of twos describing Meckel’s: 2% prevalence, 2 feet proximal to the ileocecal valve in adults, half of symptomatic Meckel’s diverticula under 2 years of age, 2 times more common in males than females.

Figure 1.

(A) Meckel’s diverticulum; (B) Appendix vermiformis.

3.3.1 Clinical findings and diagnosis

The majority are asymptomatic. They are asymptomatic unless diverticulum-related complications occur. The lifetime incidence of complications in patients with Meckel’s diverticulum is estimated to be approximately 4–6% [27].

It manifests itself with complications such as bleeding, obstruction, and diverticulitis. It may also present as Littre’s hernia, which occurs when Meckel’s diverticulum enters the hernia sac [27]. In patients younger than 18 years of age, it usually causes bleeding, while in adults it usually causes obstruction.

Twenty percent of patients with Meckel’s diverticulitis present with a clinical picture that cannot be differentiated from acute appendicitis. Carcinoid tumors are present in 0.5–3.2% of resected Meckel’s diverticula [26].

Most Meckel’s diverticula are detected radiologically, endoscopically or intraoperatively incidental. CT sensitivity for Meckel’s diverticulum is very low (Figure 2) [28]. Enteroclysis provides 75% accuracy but is usually not applicable in acute situations due to complications. Radionuclide scintigraphy is effective only in Meckel’s diverticulum containing gastric mucosa. Angiography is useful for localization in patients presenting with complications such as bleeding [28].

Figure 2.

Meckel’s diverticulum CT image.

3.3.2 Treatment

In symptomatic Meckel’s diverticulum, diverticulectomy or resection of the diverticulum segment is necessary [29]. If the cause of the symptom is bleeding, the segment containing the diverticulum should be resected. If the diverticulum contains a tumor or there is inflammation or perforation, the treatment is segmental resection.

Surgical treatment for asymptomatic Meckel’s diverticulum is not clear. In one study, prophylactic diverticulectomy should be performed on 758 asymptomatic Meckel’s diverticula to prevent Meckel-related death. Many people recommend prophylactic removal of diverticula under the age of 50 years, containing ectopic tissue and longer than 2 cm, considering the possibility of complications [30].

3.4 Diverticular disease of the colon

A diverticulum causes symptoms are called diverticular disease. Multiple diverticula without inflammation is called diverticulosis coli. If there is inflammation and infection in the diverticulum, it is called diverticulitis. The majority of colonic diverticula are false diverticula. They protrude between the tenia coli where the blood vessels enter the colon. The pathophysiology is pulsation diverticulum formed after increased intraluminal pressure.

Although the etiology of diverticulosis is not clear, studies have shown that meat products and fiber-poor diets cause smaller amounts of feces and higher intraluminal pressure is required for fecal excretion. Increased intraluminal pressure also predisposes to diverticulum formation [31]. Chronic constipation also causes increased intraluminal pressure and plays a role in the formation of pulsation diverticula. There are many theories about the etiology but none of them have been proven. It is accepted that prophylactic high fiber diets reduce the incidence of diverticula.

Only 10–20% of patients with diverticula have symptoms, the majority of them are asymptomatic. The incidence of symptoms increases with age. After the age of 50 years, the incidence increases. The most common site of diverticular diseases in the colon is the sigmoid colon and the second most common site is the descending colon. The rectum is the most rare site.

3.4.1 Clinical findings and diagnosis

Colonic diverticula, like other diverticular diseases, are usually asymptomatic. For a diverticulum to become symptomatic, an infectious condition called diverticulitis must occur. Diverticula become symptomatic when complications such as bleeding, obstruction, perforation, and abscess formation occur [32].

Diverticulitis is caused by pericolonic inflammation of the intestinal contents through the perforated colonic diverticulum. Since the sigmoid colon is the most commonly affected area, patients usually present with left lower quadrant pain. Patients may also present with changes in bowel habits, nausea, anorexia, and urgency if the bladder is affected. Bleeding from the diverticulum causes massive bleeding due to peridiverticular erosion. Most lower GI bleeding occurs in the elderly where diverticulosis or angiodysplasia is common [33]. It is difficult to determine the source of bleeding but it stops spontaneously in 80% of patients. Colonoscopic examination or angiography can be used for diagnostic and therapeutic purposes to show the bleeding diverticulum [34]. Rarely, colectomy is indicated if bleeding persists [35].

If tenderness, distension, and diffuse defensive rebound in the left lower quadrant are present on physical examination, generalized peritonitis due to diverticulum perforation is present. In addition, if there is phlegmon due to left lower quadrant diverticulum, a palpable mass may be palpated. Leukocytosis is dominant in the laboratory [36].

After a good anamnesis and physical examination, CT is very useful in the diagnosis to show the localization of the diverticulum (Figure 3), the presence of pericolonic abscess, and fistula. CT diagnosis will also guide the treatment to be performed after the diagnosis. Barium enema is not used in perforation due to the risk of intra-abdominal contamination. If oral contrast is given in CT, water-soluble contrast should be given [34]. USG and MRI can also be used in diagnosis but are not as reliable as CT. Care should be taken in colonoscopic examination in acute condition because the risk of perforation is high. Colonoscopic examination can be performed safely 4–6 weeks after the acute picture [37].

Figure 3.

Colonic diverticulas.

3.4.2 Treatment

Treatment of acute diverticulitis is divided into complicated or uncomplicated diverticula according to the clinical presentation at presentation. In complicated diverticula, abscess, fistula, free perforation, or obstruction are present. In uncomplicated diverticula, none of these complications are present, and diverticulum and pericolonic inflammation are present.

3.4.2.1 Uncomplicated diverticulitis

Uncomplicated diverticula can usually be treated on an outpatient basis with broad-spectrum oral antibiotic therapy and dietary modification. The average duration of antibiotics is 7–10 days [11]. Patients should not be immunosuppressed, afebrile, have stable vital signs, tolerate oral intake, and should not have comorbid conditions in order to be treated as outpatients. Hospitalization should be provided and iv antibiotics should be preferred in patients with fever, increased pain intensity, and leukocytosis who are not suitable for outpatient treatment. If there is no response in clinical findings within 48–72 hours, the patient should be further examined and additional pathology and complications should be investigated with imaging methods. IBD, other colitis or cancer should be ruled out with a control colonoscopic examination 4–6 weeks after the resolution of the acute picture [38].

After acute uncomplicated diverticulum attacks, 33% have a recurrent attack, but most of them are treated without hospitalization [11, 39]. About 1% of patients with recurrent attacks require surgery. In the past, elective surgery was recommended to avoid complications due to recurrences. Today, it is advocated that surgery should be decided according to the patient and comorbid conditions. This is also true in young patients. In the past, elective surgery was recommended in young (<50 years) patients after the first attack even if they were not complicated, but current guidelines do not recommend resection in young (<50 years) patients based on age.

The aim of elective surgery is to remove the affected diseased segment of the colon and anastamosis of the remaining bowel segments [40]. When the sigmoid colon is resected, if the distal part of the sigmoid colon remains, resection should be performed proximal to the rectum because of the risk of recurrence. In addition, if malignancy cannot be ruled out or the patient is immunosuppressed, surgery is indicated [15].

3.4.2.2 Complicated diverticulitis

Complicated diverticulitis includes abscess, obstruction, generalized peritonitis due to perforation or fistula of the diverticulum with adjacent organs [1].

Diverticulum-related abscesses present as pelvic or pericolic abscesses. Abscesses <2 cm are treated with parenteral antibiotics, while larger abscesses are treated with CT-guided percutaneous drainage and antibiotics (Figure 4). Failure to respond to percutaneous drainage and antibiotic treatment requires urgent surgical intervention [37, 41].

Figure 4.

An abscess due to diverticulitis.

Kaiser et al. modified Hinchey classification that is used to determine the treatment of complicated diverticulitis due to abscess in 2005 (Table 1) [42].

Stage	Modified Hincey	Hincey
Stage 0	Mild clinical diverticulitis	—
Stage 1a	Confined pericolic inflammation—phlegmon	—
Stage 1b	Confined percolic abscess	—
Stage 1	(See above)	Colonic inflammation and pericolic abscess
Stage 2	Pelvic, distant abdominal, or retroperitoneal abscess	Colonic inflammation and retroperitoneal or pelvic abscess
Stage 3	Generalized purulent peritonitis	Generalized purulent peritonitis
Stage 4	Fecal peritonitis	Generalized fecal peritonitis
Fistula	Colo-vesical/−enteric/−vaginal/−cutaneous	—
Obstruction	Large and/or small bowel obstruction	—

Table 1.

Classification of Hincey and modified Hincey stages.

Hinchey 1–2 is treated with percutaneous drainage and antibiotics if possible and primary anastamosis if the emergency situation becomes elective. Elective preoperative colonoscopic evaluation is important. Hinchey 3–4 requires emergency surgery as it presents with generalized peritonitis. Resection of the diseased segment and Hartman colostomy is recommended. In recent studies, resection anastamosis and diversion ileostomy decrease patient mortality if the patient is suitable [43, 44]. According to some opinions, laparoscopic lavage and placing a drain near the perforated area, which is thought to be the focus of peritonitis, may be one of the treatment methods in Hinchey 3 patients. This method protects the patient from emergency surgery with high morbidity.

Obstruction due to diverticulum is rare and usually heals with stricture. Treatment of partial obstruction due to diverticulum includes nasogastric decompression, fluid resuscitation, low volume water, or Gastrografin enemas. Elective surgery is possible if obstruction regresses. High-volume, oral bowel preparation is contraindicated in obstructive conditions. Emergency surgery and colectomy with primary anastamosis and diversion stoma are recommended if obstruction does not regress [44, 45].

Fistula develops between the colon and surrounding organs in 5% of complicated diverticula. Colovesical fistula is the most common. Colovaginal, coloenteric, and rarely colocutaneous fistulas are also seen [6, 36]. Frequent urinary tract infection and fecaluria may be observed in patients presenting with colovesical fistula. Air seen in the bladder on CT is useful in making the diagnosis. In a diverticulum patient presenting with fistula, malignancy, crohn’s disease, and radiation-induced fistula should be excluded and colonoscopic examination is recommended [46]. In patients who have received radiotherapy due to malignancy, fistula is considered as cancer recurrence until proven otherwise. CT and small bowel imaging can be used to determine the anatomy of the fistula. Once the anatomy of the fistula is determined, the segment including the fistula tract is treated with colectomy and repair of the affected organ [47].

3.4.3 Giant colonic diverticula

Giant colonic diverticula are rare and mostly on the antimesenteric aspect of the sigmoid colon [48]. It is important to note that giant colonic diverticula are distinct pathologic entities, and there have been reported cases of only 113 in the literature [49]. Direct radiography supports the diagnosis and barium enema is diagnostic. Complications include obstruction, perforation, and volvulus. Resection of the diseased colon and diverticula is recommended for treatment.

3.4.4 Right colon diverticula

Right colon diverticula are rare and usually asymptomatic. They usually present with right lower quadrant pain and appendicitis and are usually diagnosed intraoperatively [50]. Unlike left colon diverticula, it occurs in young patients [51]. If there is a single, large, and minimal inflammation, excision of the diverticulum can be performed; however, ileocecal resection is preferred. Bleeding is rare and management is the same as for left colonic diverticulum [52].

4. Conclusions

In this chapter, we have explored various aspects of diverticular disease, encompassing its epidemiology, etiology, pathology, and different types of diverticula in various organs of the gastrointestinal system. Diverticular disease is a complex condition with multifactorial origins, and its understanding has evolved over the years. Here, we summarize the key points discussed in this chapter.

Diverticular disease is becoming increasingly prevalent, particularly among older age groups, and its pathogenesis involves various factors such as structural abnormalities of the colonic wall, disordered intestinal motility, dietary habits, and genetic predisposition. The disease presents itself in different organs of the gastrointestinal tract, each with its own clinical manifestations and management considerations.

Duodenal diverticula, while often asymptomatic, can lead to complications such as obstruction, bleeding, and pancreatitis. Treatment options depend on the severity of symptoms and complications, with endoscopic or surgical excision being the primary approaches.

Small intestine diverticula, including Meckel’s diverticulum, are less common but can cause symptoms such as abdominal pain, nausea, and diarrhea. Surgical intervention may be required for symptomatic cases or complications such as bleeding, obstruction, or perforation.

Colonic diverticular disease is the most common form and can lead to a range of symptoms, including diverticulosis coli, diverticulitis, and diverticular bleeding. Management varies based on the presentation, with conservative approaches for uncomplicated cases and surgery for complicated diverticulitis, abscesses, or fistulas.

While this chapter provides a comprehensive overview of diverticular disease, it is essential to recognize that ongoing research and clinical guidelines continue to shape the understanding and management of this condition. Advances in diagnostic techniques, treatment strategies, and patient selection for surgery highlight the evolving landscape of diverticular disease.

In conclusion, diverticular disease represents a multifaceted gastrointestinal condition that demands a tailored approach for diagnosis and management. Clinicians must stay abreast of the latest developments in the field to provide the best care for patients with diverticular disease, ensuring that treatments are aligned with individual needs and risk factors. Continued research efforts and collaborative endeavors will further enhance our understanding of this complex disease and refine its management strategies in the future. It is preferable to include a Conclusion(s) section that will summarize the content of the book chapter.

Acknowledgments

We owe a debt of gratitude to our teachers at the Department of General Surgery, Faculty of Medicine, Çukurova University, for their support despite the recent earthquake disaster that has been affecting our country for a long time. It is with the scientific enthusiasm we received from our teachers that we are able to continue this journey we started.

Conflict of interest

The authors declare no conflict of interest.