Colonic Diverticular Disease, also known as Colonic Diverticulosis or Colonic Diverticuli is a disease of the colon (large intestine) whereby there are multiple outpouchings of the internal colonic lining that manifest as ‘bubbles’ on the external surface of the colon.
These outpouchings are known as Diverticuli (Singular: Diverticulum) and since they occur on the colon, they are known as Colonic Diverticuli.
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The Diverticuli develop at specific areas in the colon where small blood vessels known as vasa recta, penetrate through the colonic wall from the exterior to the interior to supply blood to the internal lining of the colon. As vasa recta are distributed throughout the entire length of the colon, Diverticuli can hence develop at any segment of the colon. The only exception is the Rectum which does not develop any diverticuli due to the different arrangement of the muscle fibres of the rectal wall.
The diverticuli in Colonic Diverticular disease is known as ‘propulsion’ diverticuli. They arise due to raised intra-colonic pressures that occur when the colon contract to propel faeces along. Due to the raised intra-colonic pressures over a prolonged period, the internal lining of the colon gets ‘pushed’ through these areas of weakness, hence forming outpouchings known as Diverticuli.
Despite the above explanation on the mechanism, not every person will develop diverticuli as they grow older. It has been shown that in susceptible individuals who develop diverticuli, they develop strong segmental contractions in the colon and the high pressures generated in turn lead to the development of diverticuli. It has been shown that these individuals have ‘more sensitive’ muscle receptors that lead to stronger contractions.
Colonic diverticuli, therefore, tends to occur in individuals in their 40s and older and it is certainly not the case that every person will develop diverticuli in their lifetime. We are certainly seeing patients in their 30s with diverticuli, and one postulate is the change in diet we are seeing our local population.
Smoking has been shown to increase the risk of complications related to diverticuli, such as diverticulitis (infection) and perforation. Smoking has not been proven conclusively per se to increase diverticuli formation.
Obesity is another factor that has been shown to increase the risk of developing diverticuli, with obese individuals having up to two-fold increased risk of developing complications related to diverticuli.
There has been much epidemiological research into the risk factors associated with Colonic Diverticuli. Among the risk factors studied, Dietary factors have been shown to have the strongest association with the development of diverticuli. In particular, a ‘Western’ diet of low fibre, high-fat content and high red meat intake has been identified as a risk factor with the risk of developing diverticuli increased by two- to three-fold as compared to a diet of high fibre, low-fat content and low red meat intake.
There have been concerns about the consumption of nuts and seeds causing an increase in the risk of diverticuli-related complications due to concerns about the seeds and nuts causing obstruction of the opening of the diverticuli. This has been proven to be incorrect, with the contrary being true. Consumption of nuts and popcorn have been shown to decrease the risk of infection of diverticuli.
Alcohol and Caffeine have not been shown to increase the formation of diverticuli.
In the Asian context, Colonic Diverticuli occurs in 13-25% of the population. Among the individuals with diverticuli, 9-15% of them will develop bleeding and/or infection (Diverticulitis) in their lifetime. Up to one-third of the patients with bleeding will have massive bleeding as manifested by needing blood transfusions and intervention such as surgery or embolization of vessels to stop the bleeding.
For individuals with diverticuli, the majority will have no symptoms or pain. The diverticuli are often discovered incidentally during a colonoscopy or a CT scan performed for other unrelated conditions.
As mentioned above, many individuals with diverticuli do not have symptoms nor complications related to it.
Colon diverticuli have the potential to bleed. This is because there is a small blood vessel located at the base of every diverticuli. If this blood vessel ruptures, bleeding will occur and this manifests as the passage of fresh blood in the stools. Diverticular bleeding manifests as multiple episodes of the passage of fresh blood in the stools accompanied by some ‘stomach aches’. There can also be accompanying blood clots. In the initial few passages of blood, there is often accompanying stools. However, the subsequent episodes involve only the passage of blood with no stools. In contrast, bleeding from haemorrhoids tends to only occur with the passage of stools and the blood is usually seen on wiping or as a slow drip from the anus. Most cases of diverticular bleeding do stop spontaneously after a few days. However, the individual will still need to be admitted to monitor the bleeding and for blood transfusions if necessary.
Colonic Diverticuli can be infected and this manifests as severe abdominal pain with potential fever. This is known as Diverticulitis. There may be some loose stools though not usually frank diarrhoea. These are known as Uncomplicated Diverticulitis and treatment is that of intravenous and oral antibiotics.
In a severe situation of diverticulitis (infection of diverticuli), a perforation (hole) can develop in the colon with leakage of faeces into the abdominal cavity. This can be contained and form an intra-abdominal abscess (collection of pus and faeces). In the case of an abscess formation, surgery may be averted by inserting a drain (plastic tube) into the abscess cavity to drain the pus in combination with antibiotics.
Sometimes, there is uncontained widespread faecal contamination of the abdominal cavity and this necessitates emergency surgery.
Colonic Diverticuli is also known to develop an abnormal communicating channel (fistula) with neighbouring organs, in particular the bladder and vagina. This results in faeces discharging from the urine or the vagina. Surgery is needed in these circumstances to resolve the problem.
Some patients with colonic diverticuli may have abdominal pain in the absence of inflammation (diverticulitis). This is a condition known as SUDD (Symptomatic Uncomplicated Diverticular Disease). The underlying cause of the pain is postulated to be Colonic Dysmotility (abnormal contractions of the colon) and Visceral Hypersensitivity (increased pain sensitivity of the intestine).
Surgery is only needed to treat Complicated Colonic Diverticulosis in a few situations.
Emergency surgery will be needed in bleeding diverticuli if the bleeding does not stop spontaneously and if other measures to stop the bleeding (such as catheter-directed embolization) fails. The patient will usually be unstable in such situations and expedient surgery is necessary.
Emergency surgery will similarly be needed in situations where there is a perforation (hole) in the colon and there is widespread faecal contamination of the abdominal cavity. In such situations, there is a higher likelihood that a stoma may be created. A stoma is created by bringing a loop of the colon or small intestine to the skin and allowing the faces to discharge into a stoma bag.
In individuals with multiple attacks of diverticulitis (infection), recurrent admissions for bleeding, abnormal fistula tract to neighbouring organs or a colonic stricture (narrowing of the colon) as a result of colonic diverticulosis, surgery will be needed to resolve the problem. Surgery in such circumstances is usually undertaken in the elective/non-urgent setting and can potentially be performed as a laparoscopic (keyhole) surgery.