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{{Diverticulitis}}
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==Overview==
==Overview==
Diverticulitis is a common [[digestive disease]] particularly found in the colon (the large intestine).<ref name="CDCNIDDK">Diverticulosis and Diverticulitis. National Institute of Health - National Institute of Diabetes and Digestive and Kidney Diseases (2016). https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/diverticulosis-diverticulitis/Pages/overview.aspx Accessed on July 28, 2016 </ref> Diverticulitis develops from [[diverticulosis]], which involves the formation of pouches ([[diverticula]]) on the outside of the [[colon (anatomy)|colon]]. Diverticulitis results if one of these diverticula becomes [[inflamed]] or infected.<ref name="Merriam">[http://medical.merriam-webster.com/medical/diverticulitis Diverticulitis] entry at Merriam Webster's Medical dictionary</ref> The colon can become infected with craters of food stuck inside, which causes abdominal pain.
Diverticulitis is a common disease of the [[digestive tract]] that affects the [[colon]]. Diverticulitis develops from [[diverticulosis]], which involves the formation of pouches (diverticula) on the outside of the [[colon (anatomy)|colon]]. Diverticulitis results when one of these diverticula becomes [[inflamed]] or infected. The colon can become infected with pieces of food stuck inside, leading to [[abdominal pain]]. Diverticulitis can be classified into asymptomatic, symptomatic, complicated, uncomplicated, acute and recurrent. The [[prevalence]] of diverticulitis is 20,000 individuals at age 40 and 60,000 at age 60. The highest [[incidence]] is in patients between 18 to 44 years old. Men and women are equally affected by diverticulitis between 50-70. Risk factors of diverticulitis are multiple [[Diverticulum|diverticula]] and [[intraperitoneal]] [[abscess]].  Diverticulitis can cause many complications as [[abscess]], [[Bowel perforation|perforation]], [[peritonitis]], and [[fistula]] formation. Symptoms of diverticulitis include [[Abdominal pain|left lower abdominal pain]], [[fever]], [[Cramp|cramps]], and [[constipation]]. Common physical examination findings include [[tachycardia]], [[fever]], [[abdominal tenderness]], [[guarding]] and [[rebound tenderness]], and presence of a palpable [[mass]]. The mainstay of therapy for acute diverticulitis is usually conservative medical management, including [[bowel]] rest, intravenous [[fluid]] [[resuscitation]], and [[Broad-spectrum antibiotics|broad-spectrum antimicrobial therapy]] that covers [[Anaerobic organism|anaerobic]] [[bacteria]] and [[gram-negative]] [[Bacteria|rods]].  


==Historical Perspective==
==Historical Perspective==
The diverticulum history itself goes back to 1700s when Dr. Lavater described the diverticulum and in 1812 Dr. Meckel gave a full description on it. In 1700s, Dr. Littre was the first to describe diverticular diseases.
Diverticulitis was first described by Dr. Lavater in the 1700s. In the 18th century, Dr. Littre was the first person to describe the [[diverticular disease]]. Dr. Meckel gave a full description of the [[diverticulum]] in 1812.


==Classification==
==Classification==
Diverticulitis may be classified according to the German guidelines which were recently (2014) passed by the German Societies of Gastroenterology (DGVS) and of Visceral Surgery (DGAV). They unanimously agreed on another classification (Classification of Diverticular Disease (CDD)), which takes practical algorithms (symptomatic, asymptomatic, complicated, uncomplicated, acute, recurrent), ongoing surgical aspects (purulent vs. fecal peritonitis), and contemporary diagnostic standards in clinical practice into account. As a result, this classification comprises the entire spectrum of diverticular disease.<ref name="pmid2502600">{{cite journal| author=DeJoy SQ, Ferguson KM, Sapp TM, Zabriskie JB, Oronsky AL, Kerwar SS| title=Streptococcal cell wall arthritis. Passive transfer of disease with a T cell line and crossreactivity of streptococcal cell wall antigens with Mycobacterium tuberculosis. | journal=J Exp Med | year= 1989 | volume= 170 | issue= 2 | pages= 369-82 | pmid=2502600 | doi= | pmc=2189401 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2502600  }} </ref>
Diverticulitis may be classified according to the 2014 guidelines by the German Societies of Gastroenterology (DGVS) and of Visceral Surgery (DGAV). They unanimously agreed on a classification system (Classification of Diverticular Disease (CDD)), that takes practical algorithms (symptomatic, asymptomatic, complicated, uncomplicated, acute, recurrent), ongoing surgical aspects ([[purulent]] versus fecal [[peritonitis]]), and contemporary diagnostic standards in clinical practice into account. As a result, this classification comprises the entire spectrum of diverticular disease.


==Pathophysiology==
==Pathophysiology==
Diverticula is a protrusion of the intestinal layers consisting of mucosa and serosa. It occurs mainly on the left side more than the right side. Diverticulitis is the inflammation of this protrusion. It is believed that the first step in the pathogenesis of diverticulitis is the increase of intraluminal pressure, change of the intestinal motility and bacterial colonization. The inflammation is caused by histamine, tumor necrosis factor, and metalloproteinases which were found in diverticulitis patient's tissue biopsies. Obstruction of the diverticula leads to bacteria colonization which leads to inflammation in the end.
Diverticula are protrusions of the [[mucosal]] and [[serosa|serosal]] [[intestinal]] layers and occur more often on the left side than the right side. Diverticulitis is the [[inflammation]] of these protrusions. The first steps in the pathogenesis of diverticulitis are an increase in [[intraluminal]] [[pressure]], change in [[intestinal]] [[motility]], and [[Bacterial infection|bacterial colonization]]. The [[inflammation]] is caused by [[histamine]], [[tumor necrosis factor]], and [[Metalloproteinase|metalloproteinases]], which have been found in diverticulitis patients' [[tissue]] [[biopsies]]. [[Obstruction]] of the [[Diverticulum|diverticula]] leads to [[Bacterial infection|bacterial colonization]], which causes [[inflammation]].


==Causes==
==Causes==
Common causes of diverticulitis include [[diverticulosis]], a low-fiber diet, [[constipation]], abdominal distension, and [[Meckel's diverticulum]].
Common causes of diverticulitis include [[diverticulosis]], a low-fiber diet, [[constipation]], [[abdominal distension]], and [[Meckel's diverticulum]].


==Differentiating diverticulitis from Other Diseases==
==Differentiating Diverticulitis from Other Diseases==
It is important to differentiate sigmoid diverticulitis from a lot of inflammatory and non-inflammatory diseases of the gastrointestinal tract and the urogenital system. Differential diagnosis of diverticulitis can be based on the diseases causing [[lower abdominal pain]] and [[fever]], and the diseases causing [[peritonitis]]. Diverticulitis can be differentiated from other diseases that cause lower abdominal pain and fever like [[appendicitis]], [[inflammatory bowel disease]], [[colon cancer]], [[cystitis]] and [[endometritis]].
Diverticulitis must be differentiated from other [[diseases]] that cause [[lower abdominal pain]] and [[fever]], such as [[appendicitis]], [[inflammatory bowel disease]], [[colon cancer]], [[cystitis]], and [[endometritis]]. Diverticulitis must be also differentiated from diseases causing [[peritonitis]].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
The prevalance of diverticulitis is 20,000 individuals at age 40 and 60,000 at age 60. The greater incidence is in patients between 18 to 44 years. Men and women are equally affected by diverticulitis at age 50-70 years and men are more affected at age more than 70 years. The prevalence has increased in the developed countries. In the United States it has been around 312,000 cases admitted to the hospitals. In Japan, more cases of right side diverticulitis have been reported compared to the left side.<ref name="pmid1109818">{{cite journal| author=Painter NS, Burkitt DP| title=Diverticular disease of the colon, a 20th century problem. | journal=Clin Gastroenterol | year= 1975 | volume= 4 | issue= 1 | pages= 3-21 | pmid=1109818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1109818  }} </ref><ref name="pmid11052515">{{cite journal| author=Miura S, Kodaira S, Shatari T, Nishioka M, Hosoda Y, Hisa TK| title=Recent trends in diverticulosis of the right colon in Japan: retrospective review in a regional hospital. | journal=Dis Colon Rectum | year= 2000 | volume= 43 | issue= 10 | pages= 1383-9 | pmid=11052515 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11052515  }} </ref>
The [[prevalence]] of diverticulitis is 20,000 individuals at age 40 and 60,000 at age 60. The highest [[incidence]] is in patients between 18 to 44 years old. Men and women are equally affected by diverticulitis between 50-70, but men above 70 are more commonly affected than women. The [[prevalence]] of diverticulitis has increased in developed countries. In the United States, approximately 312,000 cases are admitted to the hospitals. In Japan, more cases of right side diverticulitis have been reported than cases of left side diverticulitis.


==Risk Factors==
==Risk Factors==
Risk factors in the development of diverticulitis include advanced age, chronic [[constipation]], [[connective tissue disease]]s (such as [[Marfan syndrome]] or [[Ehlers Danlos syndrome]]), low dietary fiber intake, high intake of fat and red meat, and obesity. There are risk factors for the disease recurrence as well. These factors include multiple diverticula, intraperitoneal abscess, family history of diverticulitis, and a great portion of the colon involved in the disease.
The most potent [[risk factors]] for disease recurrence include multiple [[Diverticulum|diverticula]][[intraperitoneal]] [[abscess]], family history of diverticulitis, and having a large portion of the [[colon]] involved in the disease.


==Screening==
==Screening==
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==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
Diverticulitis natural history is not well understood, but some studies showed a benign course if kept untreated. Diverticulitis can cause many complications that could be fatal in some cases. These complications include abscess, perforation, peritonitis and fistula formation. Prognosis of diverticulitis is excellent and conservative treatment is successful in 70 to 100 percent of patients.
Diverticulitis natural history is not well understood. Diverticulitis can cause many complications that can be fatal in some cases. These complications include [[abscess]], [[Bowel perforation|perforation]], [[peritonitis]], and [[fistula]] formation. Prognosis of diverticulitis is excellent and conservative treatment is successful in 70 to 100 percent of patients.


==Diagnosis==
==Diagnosis==
===History and Symptoms===
===History and Symptoms===
When taking a medical history, the doctor may ask about [[bowel]] habits, [[pain]], other symptoms, [[diet]], and [[medications]]. The physical exam usually involves a digital [[rectal]] exam. To perform this test, the doctor inserts a gloved, lubricated finger into the [[rectum]] to detect [[tenderness]], blockage, or [[blood]]. The doctor may check [[stool]] for signs of [[bleeding]] and test [[blood]] for signs of [[infection]].
The most common symptoms of diverticulitis include [[Abdominal pain|left lower abdominal pain]], [[fever]], [[Cramp|cramps]], and [[constipation]]. A positive history of change in [[bowel]] habits is suggestive of diverticulitis. Less common symptoms include [[flatulence]][[nausea]], and [[vomiting]].


===Physical Examination===
===Physical Examination===
Diverticulitis diagnosis depends on taking a proper [[History & Symptoms|history]] and doing [[physical examination]]. The known [[diagnostic criteria]] for diverticulitis includes [[abdominal tenderness]] especially in the [[Left lower quadrant abdominal pain resident survival guide|left lower quadrant]], [[leukocytosis]] and CT scan findings helps in [[disease]] confirmation. [[Fever]] is common in diverticulitis patients. Abdominal examination will reveal [[tenderness]], [[decreased bowel sounds]] and palpable [[mass]] may be felt. In some patients, [[genitourinary]] signs of [[cystitis]] would occur due to [[bladder]] [[irritation]].<ref name="pmid3536213">{{cite journal| author=Thompson WG, Patel DG| title=Clinical picture of diverticular disease of the colon. | journal=Clin Gastroenterol | year= 1986 | volume= 15 | issue= 4 | pages= 903-16 | pmid=3536213 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3536213  }} </ref>
Patients with diverticulitis usually appear toxic due to pain. Common physical examination findings include [[tachycardia]], [[fever]], [[abdominal tenderness]], [[guarding]] and [[rebound tenderness]], and presence of a palpable [[mass]]. Diverticulitis diagnosis depends on taking a proper [[History & Symptoms|history]] and performing a [[physical examination]]. The known [[diagnostic criteria]] for diverticulitis include [[abdominal tenderness]], especially in the [[Left lower quadrant abdominal pain resident survival guide|left lower quadrant]], and [[leukocytosis]]. CT scan findings help in [[disease]] confirmation.


===Laboratory Findings===
===Laboratory Findings===
Diverticulitis diagnosis starts by taking history precisely and perform physical examination. Lab tests are important in excluding other causes of [[abdominal pain]] and any other [[Gastrointestinal diseases|gastrointestinal disease]]. These lab tests include [[Complete blood count|CBC]], [[CRP]], [[urinalysis]] and [[liver]] tests. Imaging procedures are important measures in diagnosing diverticulitis including the CT scan and [[colonoscopy]].<ref name="pmid16741596">{{cite journal| author=Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons| title=Practice parameters for sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 7 | pages= 939-44 | pmid=16741596 | doi=10.1007/s10350-006-0578-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16741596  }} </ref><ref name="pmid20645093">{{cite journal| author=Käser SA, Fankhauser G, Glauser PM, Toia D, Maurer CA| title=Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis. | journal=World J Surg | year= 2010 | volume= 34 | issue= 11 | pages= 2717-22 | pmid=20645093 | doi=10.1007/s00268-010-0726-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20645093  }} </ref>
Diverticulitis diagnosis starts by taking history precisely and performing a physical examination. Lab tests are important in excluding other causes of [[abdominal pain]] and any other [[Gastrointestinal diseases|gastrointestinal disease]]. These lab tests include [[Complete blood count|CBC]], [[CRP]], [[urinalysis]], and [[liver]] tests. Imaging procedures including CT scan and [[colonoscopy]] are important measures in diagnosing diverticulitis.<ref name="pmid16741596">{{cite journal| author=Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons| title=Practice parameters for sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 7 | pages= 939-44 | pmid=16741596 | doi=10.1007/s10350-006-0578-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16741596  }} </ref><ref name="pmid20645093">{{cite journal| author=Käser SA, Fankhauser G, Glauser PM, Toia D, Maurer CA| title=Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis. | journal=World J Surg | year= 2010 | volume= 34 | issue= 11 | pages= 2717-22 | pmid=20645093 | doi=10.1007/s00268-010-0726-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20645093  }} </ref>


===CT scan===
===CT scan===
The CT scan is very sensitive (98%) in diagnosing diverticulitis. Using [[oral]] or [[intravenous]] contrast will have a good impact on the [[CT scan]] accuracy. It may also identify [[patients]] with more complicated diverticulitis, such as those with an associated [[abscess]]. CT also allows for radiologically guided drainage of associated abscesses, possibly sparing a patient from immediate surgical intervention. CT scan is not only important in the diagnosis of diverticulitis but also needed to exclude the [[cancer]] possibility in these patients.<ref name="pmid26019048">{{cite journal| author=Schreyer AG, Layer G, German Society of Digestive and Metabolic Diseases (DGVS) as well as the German Society of General and Visceral Surgery (DGAV) in collaboration with the German Radiology Society (DRG)| title=S2k Guidlines for Diverticular Disease and Diverticulitis: Diagnosis, Classification, and Therapy for the Radiologist. | journal=Rofo | year= 2015 | volume= 187 | issue= 8 | pages= 676-84 | pmid=26019048 | doi=10.1055/s-0034-1399526 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26019048  }} </ref><ref name="pmid2657852">{{cite journal| author=Neff CC, vanSonnenberg E| title=CT of diverticulitis. Diagnosis and treatment. | journal=Radiol Clin North Am | year= 1989 | volume= 27 | issue= 4 | pages= 743-52 | pmid=2657852 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2657852  }} </ref><ref name="pmid27574459">{{cite journal| author=Ambrosetti P| title=Acute left-sided colonic diverticulitis: clinical expressions, therapeutic insights, and role of computed tomography. | journal=Clin Exp Gastroenterol | year= 2016 | volume= 9 | issue=  | pages= 249-57 | pmid=27574459 | doi=10.2147/CEG.S110428 | pmc=4993273 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27574459  }} </ref><ref name="pmid24874087">{{cite journal| author=Andeweg CS, Wegdam JA, Groenewoud J, van der Wilt GJ, van Goor H, Bleichrodt RP| title=Toward an evidence-based step-up approach in diagnosing diverticulitis. | journal=Scand J Gastroenterol | year= 2014 | volume= 49 | issue= 7 | pages= 775-84 | pmid=24874087 | doi=10.3109/00365521.2014.908475 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24874087  }} </ref><ref name="pmid17255417">{{cite journal| author=Goh V, Halligan S, Taylor SA, Burling D, Bassett P, Bartram CI| title=Differentiation between diverticulitis and colorectal cancer: quantitative CT perfusion measurements versus morphologic criteria--initial experience. | journal=Radiology | year= 2007 | volume= 242 | issue= 2 | pages= 456-62 | pmid=17255417 | doi=10.1148/radiol.2422051670 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17255417  }} </ref>
Abdominal CT scan is helpful in the diagnosis of diverticulitis. CT is not only important in the diagnosis of diverticulitis but is also necessary to exclude the possibility of [[cancer]] in patients. CT may also identify patients with complicated diverticulitis, such as those with an associated [[abscess]]. CT also allows for radiologically guided drainage of associated [[abscesses]], possibly sparing a patient from immediate surgical intervention.


===MRI===
===MRI===
MRI is a good imaging modality that can be used in diagnosis of diverticulitis since it has an advantage that there is no exposure to [[radiation]] and it rules out other [[abdominal]] causes of [[acute abdomen]]. However, it is not the best diagnostic procedure to diagnose diverticulitis and CT scan is preferred more. MRI shows specific findings of diverticulitis which include thickening of the [[colon]] wall, presence of the [[Diverticular|diverticula]], and [[Exudate|exudates]] out of the colon. It may also shows presence of multiple [[abscesses]].<ref name="pmid10566700">{{cite journal| author=Stollman NH, Raskin JB| title=Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. | journal=Am J Gastroenterol | year= 1999 | volume= 94 | issue= 11 | pages= 3110-21 | pmid=10566700 | doi=10.1111/j.1572-0241.1999.01501.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10566700  }} </ref><ref name="pmid8518890">{{cite journal| author=McKee RF, Deignan RW, Krukowski ZH| title=Radiological investigation in acute diverticulitis. | journal=Br J Surg | year= 1993 | volume= 80 | issue= 5 | pages= 560-5 | pmid=8518890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8518890  }} </ref>
On abdominal MRI, diverticulitis is characterized by thickening of the [[colon]] wall, the presence of the [[Diverticular|diverticula]], and [[Exudate|exudates]] from the colon. It may also show the presence of multiple [[abscesses]]. MRI is a good imaging modality that can be used in the diagnosis of diverticulitis since it has the advantage that it doesn't involve exposure to [[radiation]] and rules out other [[abdominal]] causes of [[acute abdomen]]. However, MRI is not the best diagnostic procedure for diverticulitis; CT scan is preferred.


===Ultrasound===
===Ultrasound===
[[Meckel's diverticula]] are usually seen as [[tubular]] incompressible blind ending hypoechoic structures with irregular margins. Occasionally it may also be seen as a [[cyst]], raising a different differential diagnosis of [[intestinal]] duplication which however, is said to have a regular margin.
On abdominal ultrasonography, diverticulitis is characterized by [[abscess]] formation, [[gas]] bubbles, the presence of [[Diverticulum|diverticula]], and thickening of the [[colon]] segments. Extra diverticular [[Exudate|exudates]] and [[fluids]] can be also observed. 


===X ray===
===X-ray===
X ray is a supportive [[diagnostic]] [[modality]] to diverticulitis although it is not the best modality. It can be used in case the CT scan is not available and in the uncomplicated cases. The radiographies used are  [[abdominal]] [[x ray]], [[barium enema]] and [[Chest X-ray|chest x-ray]]. The barium enema has disadvantages, as it can cause [[rupture]] and
On [[abdominal]] X-ray, diverticulitis is characterized by multiple air and fluid levels if there is an [[intestinal perforation]]. Chest X-ray should be done in patients with diverticulitis to investigate for [[pneumoperitoneum]], which is a harbinger of a critical [[illness]] and will lead to a change in the management plan for the case. X-ray can be used if CT is not available and in uncomplicated cases.
[[peritonitis]]. Abdominal x-ray shows multiple [[air]] and [[fluid]] levels in case of [[intestinal]] perforation. Chest x-ray is important to be done in patients with diverticulitis to investigate for the [[pneumoperitoneum]]; which is a harbinger to a critical [[illness]] and will lead to change in the management plan in the case.


===Other imaging findings===
===Other imaging findings===
There are no other specific imaging findings for diverticulitis. Other studies, such as [[barium enema]] and [[colonoscopy]] are contraindicated in the acute phase of diverticulitis due to the risk of [[perforation]].
There are no other specific imaging findings for diverticulitis. Other studies such as [[barium enema]] and [[colonoscopy]] are contraindicated in the acute phase of diverticulitis due to the risk of [[perforation]].


===Other diagnostic studies===
===Other diagnostic studies===
There are no other specific diagnostic studies for diverticulitis. Other studies, such as [[barium enema]] and [[colonoscopy]] are contraindicated in the acute phase of diverticulitis due to the risk of [[perforation]].
There are no other specific diagnostic studies for diverticulitis. Other studies such as [[barium enema]] and [[colonoscopy]] are contraindicated in the acute phase of diverticulitis due to the risk of [[perforation]].


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
An initial episode of acute diverticulitis is usually treated with conservative medical management, including bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy which covers [[Anaerobic organism|anaerobic]] [[bacteria]] and [[gram-negative]] [[Bacteria|rods]]. Patients who have recurring acute attacks or who develop diverticulitis-associated complications, such as peritonitis, abscess, or fistula, require surgery, either immediately or on an elective basis.
The mainstay of therapy for acute diverticulitis is usually conservative medical management, including [[bowel]] rest, intravenous [[fluid]] [[resuscitation]], and [[Broad-spectrum antibiotics|broad-spectrum antimicrobial therapy]] that covers [[Anaerobic organism|anaerobic]] [[bacteria]] and [[gram-negative]] [[Bacteria|rods]]. Patients who have recurring acute attacks or who develop diverticulitis-associated complications, such as [[peritonitis]], [[abscess]], or [[fistula]], require surgery either immediately or on an elective basis.


===Surgery===
===Surgery===
If symptoms of diverticulitis are frequent, or the patient does not respond to [[antibiotics]] and resting the [[colon]], the doctor may advise [[surgery]]. The surgeon removes the affected part of the [[colon]] and joins the remaining sections. This type of surgery—called colon [[resection]]—aims to prevent complications and future diverticulitis. The doctor may also recommend surgery for complications such as a [[fistula]] or partial [[intestinal]] [[obstruction]].
Surgery is not the first-line treatment option for patients with diverticulitis. Emergency or urgent surgery is usually reserved for patients complicated with [[peritonitis]], who are unresponsive to treatment, who have [[intestinal obstruction]], or with [[abscess]] formation. Elective surgery may be performed and it depends on many factors like the age of the patient, severity score, and persistence of symptoms.
 
Immediate surgery may be necessary when the patient has other complications, such as [[perforation]], a large [[abscess]], [[peritonitis]], complete [[intestinal]] [[obstruction]], or severe [[bleeding]]. In these cases, two surgeries may be needed because it is not safe to rejoin the colon right away. During the first surgery, the surgeon cleans the infected [[abdominal cavity]], removes the portion of the affected [[colon]], and performs a temporary [[colostomy]], creating an opening, or [[stoma]], in the [[abdomen]]. The end of the colon is connected to the opening to allow normal eating, while healing occurs. [[Stools|Stool]] is collected in a pouch attached to the stoma. In the second surgery several months later, the surgeon rejoins the ends of the colon and closes the stoma.


===Prevention===
===Prevention===
Primary prevention of diverticulitis follows the prevention of  constipation by using osmotic agents like lactulose, polyethylene glycol or magnesium salts. High fiber diet should be given till constipation improves. Usage of laxatives and drinking plenty of fluids daily will be helpful.
Primary prevention of diverticulitis follows the prevention of [[constipation]] by using [[osmotic]] agents like [[lactulose]], [[polyethylene glycol]], or [[magnesium]] salts. A high [[fiber]] diet should be given until [[constipation]] improves. Using [[laxatives]] and drinking plenty of [[fluids]] daily will be helpful.


==References==
==References==
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{{Reflist|2}}
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[[Category:Surgery]]
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Ahmed Elsaiey, MBBCH [3]

Overview

Diverticulitis is a common disease of the digestive tract that affects the colon. Diverticulitis develops from diverticulosis, which involves the formation of pouches (diverticula) on the outside of the colon. Diverticulitis results when one of these diverticula becomes inflamed or infected. The colon can become infected with pieces of food stuck inside, leading to abdominal pain. Diverticulitis can be classified into asymptomatic, symptomatic, complicated, uncomplicated, acute and recurrent. The prevalence of diverticulitis is 20,000 individuals at age 40 and 60,000 at age 60. The highest incidence is in patients between 18 to 44 years old. Men and women are equally affected by diverticulitis between 50-70. Risk factors of diverticulitis are multiple diverticula and intraperitoneal abscess. Diverticulitis can cause many complications as abscess, perforation, peritonitis, and fistula formation. Symptoms of diverticulitis include left lower abdominal painfevercramps, and constipation. Common physical examination findings include tachycardiafeverabdominal tenderness, guarding and rebound tenderness, and presence of a palpable mass. The mainstay of therapy for acute diverticulitis is usually conservative medical management, including bowel rest, intravenous fluid resuscitation, and broad-spectrum antimicrobial therapy that covers anaerobic bacteria and gram-negative rods.

Historical Perspective

Diverticulitis was first described by Dr. Lavater in the 1700s. In the 18th century, Dr. Littre was the first person to describe the diverticular disease. Dr. Meckel gave a full description of the diverticulum in 1812.

Classification

Diverticulitis may be classified according to the 2014 guidelines by the German Societies of Gastroenterology (DGVS) and of Visceral Surgery (DGAV). They unanimously agreed on a classification system (Classification of Diverticular Disease (CDD)), that takes practical algorithms (symptomatic, asymptomatic, complicated, uncomplicated, acute, recurrent), ongoing surgical aspects (purulent versus fecal peritonitis), and contemporary diagnostic standards in clinical practice into account. As a result, this classification comprises the entire spectrum of diverticular disease.

Pathophysiology

Diverticula are protrusions of the mucosal and serosal intestinal layers and occur more often on the left side than the right side. Diverticulitis is the inflammation of these protrusions. The first steps in the pathogenesis of diverticulitis are an increase in intraluminal pressure, change in intestinal motility, and bacterial colonization. The inflammation is caused by histamine, tumor necrosis factor, and metalloproteinases, which have been found in diverticulitis patients' tissue biopsies. Obstruction of the diverticula leads to bacterial colonization, which causes inflammation.

Causes

Common causes of diverticulitis include diverticulosis, a low-fiber diet, constipation, abdominal distension, and Meckel's diverticulum.

Differentiating Diverticulitis from Other Diseases

Diverticulitis must be differentiated from other diseases that cause lower abdominal pain and fever, such as appendicitisinflammatory bowel diseasecolon cancercystitis, and endometritis. Diverticulitis must be also differentiated from diseases causing peritonitis.

Epidemiology and Demographics

The prevalence of diverticulitis is 20,000 individuals at age 40 and 60,000 at age 60. The highest incidence is in patients between 18 to 44 years old. Men and women are equally affected by diverticulitis between 50-70, but men above 70 are more commonly affected than women. The prevalence of diverticulitis has increased in developed countries. In the United States, approximately 312,000 cases are admitted to the hospitals. In Japan, more cases of right side diverticulitis have been reported than cases of left side diverticulitis.

Risk Factors

The most potent risk factors for disease recurrence include multiple diverticulaintraperitoneal abscess, family history of diverticulitis, and having a large portion of the colon involved in the disease.

Screening

There is insufficient evidence to recommend routine screening for diverticulitis.

Natural History, Complications, and Prognosis

Diverticulitis natural history is not well understood. Diverticulitis can cause many complications that can be fatal in some cases. These complications include abscess, perforation, peritonitis, and fistula formation. Prognosis of diverticulitis is excellent and conservative treatment is successful in 70 to 100 percent of patients.

Diagnosis

History and Symptoms

The most common symptoms of diverticulitis include left lower abdominal painfevercramps, and constipation. A positive history of change in bowel habits is suggestive of diverticulitis. Less common symptoms include flatulencenausea, and vomiting.

Physical Examination

Patients with diverticulitis usually appear toxic due to pain. Common physical examination findings include tachycardiafeverabdominal tenderness, guarding and rebound tenderness, and presence of a palpable mass. Diverticulitis diagnosis depends on taking a proper history and performing a physical examination. The known diagnostic criteria for diverticulitis include abdominal tenderness, especially in the left lower quadrant, and leukocytosis. CT scan findings help in disease confirmation.

Laboratory Findings

Diverticulitis diagnosis starts by taking history precisely and performing a physical examination. Lab tests are important in excluding other causes of abdominal pain and any other gastrointestinal disease. These lab tests include CBC, CRP, urinalysis, and liver tests. Imaging procedures including CT scan and colonoscopy are important measures in diagnosing diverticulitis.[1][2]

CT scan

Abdominal CT scan is helpful in the diagnosis of diverticulitis. CT is not only important in the diagnosis of diverticulitis but is also necessary to exclude the possibility of cancer in patients. CT may also identify patients with complicated diverticulitis, such as those with an associated abscess. CT also allows for radiologically guided drainage of associated abscesses, possibly sparing a patient from immediate surgical intervention.

MRI

On abdominal MRI, diverticulitis is characterized by thickening of the colon wall, the presence of the diverticula, and exudates from the colon. It may also show the presence of multiple abscesses. MRI is a good imaging modality that can be used in the diagnosis of diverticulitis since it has the advantage that it doesn't involve exposure to radiation and rules out other abdominal causes of acute abdomen. However, MRI is not the best diagnostic procedure for diverticulitis; CT scan is preferred.

Ultrasound

On abdominal ultrasonography, diverticulitis is characterized by abscess formation, gas bubbles, the presence of diverticula, and thickening of the colon segments. Extra diverticular exudates and fluids can be also observed. 

X-ray

On abdominal X-ray, diverticulitis is characterized by multiple air and fluid levels if there is an intestinal perforation. Chest X-ray should be done in patients with diverticulitis to investigate for pneumoperitoneum, which is a harbinger of a critical illness and will lead to a change in the management plan for the case. X-ray can be used if CT is not available and in uncomplicated cases.

Other imaging findings

There are no other specific imaging findings for diverticulitis. Other studies such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.

Other diagnostic studies

There are no other specific diagnostic studies for diverticulitis. Other studies such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.

Treatment

Medical Therapy

The mainstay of therapy for acute diverticulitis is usually conservative medical management, including bowel rest, intravenous fluid resuscitation, and broad-spectrum antimicrobial therapy that covers anaerobic bacteria and gram-negative rods. Patients who have recurring acute attacks or who develop diverticulitis-associated complications, such as peritonitisabscess, or fistula, require surgery either immediately or on an elective basis.

Surgery

Surgery is not the first-line treatment option for patients with diverticulitis. Emergency or urgent surgery is usually reserved for patients complicated with peritonitis, who are unresponsive to treatment, who have intestinal obstruction, or with abscess formation. Elective surgery may be performed and it depends on many factors like the age of the patient, severity score, and persistence of symptoms.

Prevention

Primary prevention of diverticulitis follows the prevention of constipation by using osmotic agents like lactulosepolyethylene glycol, or magnesium salts. A high fiber diet should be given until constipation improves. Using laxatives and drinking plenty of fluids daily will be helpful.

References

  1. Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons (2006). "Practice parameters for sigmoid diverticulitis". Dis Colon Rectum. 49 (7): 939–44. doi:10.1007/s10350-006-0578-2. PMID 16741596.
  2. Käser SA, Fankhauser G, Glauser PM, Toia D, Maurer CA (2010). "Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis". World J Surg. 34 (11): 2717–22. doi:10.1007/s00268-010-0726-7. PMID 20645093.

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