The publisher’s sale of this reprint does not constitute or imply any endorsement or sponsorship of any project, service, company or organization. Minnesota Physician Reprints (612-728-8600) • 2812 East 26th Street, Mpls., MN 55406. Do not edit or alter reprints. Reproductions not permitted. MINNESOTA Your Guide to Consumer Information December 2008 • Volume 6 Number 12 D iverticular disease is the fifth most important gastrointesti- nal condition in terms of direct and indirect health care costs in Western countries. People with this condition usually have no symptoms, but complications can lead to hospitalization and rarely, death. Diverticulosis describes the presence of several pocket-like protrusions along the colon wall. A single pocket is called a diverticulum. When these pockets become inflamed or infected, the condition is referred to as diverti- culitis. Diverticular disease includes both diverticulosis and diverticulitis. Although diverticulosis is now common in both men and women, it was virtually unknown in the previous century. The incidence of diverticular disease in westernized countries has increased from a range of 5 percent to 10 percent 80 years ago to 35 percent to 50 percent today. It is increasingly common with advancing age; it is estimated that up to 65 percent of people over 80 years of age have this condition. Diverticulosis progresses to diverticulitis in roughly 15 percent to 25 percent of people with diverticular disease. Nearly all diverticulitis is mild, and it usually responds well to medical treatment. Causes Diverticular disease is more common in developed countries, which suggests that lifestyle and environment signifi- cantly contribute to the development of this condition. While specific triggers of divertic- ulitis are not known, the most impor- tant factor influencing the develop- ment of diverticulosis is diet. It is known that low dietary fiber increases the chance of developing diverticulo- sis. Diverticulosis is rare in underde- veloped countries unless a westernized diet has been adopted. Lifelong vege- tarians also seem to have fewer diver- ticula, most likely because fruits and vegetables are important sources of fiber and represent the majority of the vegetarian diet. A low-fiber diet caus- es constipation—small, hard stools that put pressure on colon walls, pushing the walls outward. Frequent, abnormal contractions or spasms of the colon wall are found in this condi- tion and also increase colonic wall pressure. Over time, weaknesses in the walls develop into diverticula. Dietary fiber counteracts this process by soft- ening stools. Softer stool passes through the colon faster, thus limiting pressure on the walls of the colon. Other factors influencing divertic- ulosis may include physical activity, obesity, and genetic predisposition. However, how exercise prevents diver- ticulosis is unknown, and evidence for the role of obesity is controversial. Symptoms Diverticulosis usually has no symp- toms and is most often found inciden- tally. Mild symptoms can include occasional bloating; flatulence; irregu- lar stools; hard, pellet-like stools; or attacks of diarrhea. Major complica- tions of diverticulosis include divertic- ulitis and diverticular bleeding. The most common symptom of diverticulitis is pain in the left lower abdomen; the severity of symptoms depends on the extent and degree of inflammation. Nausea, vomiting, fever, constipation, diarrhea, problems with urination, and rectal bleeding can also occur. Diverticulitis can range from mild, single attacks to severe, recurrent disease. Complicated diverti- culitis involves the formation of an abscess (collection of pus), a fistula (an abnormal tract between organs), obstruction or blockage of the colon, perforation (a hole in the colon), or sepsis (overwhelming infection spread- ing throughout the body). Cases like these require hospitalization. Diverticular bleeding occurs in 3 percent to 5 percent of people with diverticulosis. Diverticula are formed near blood vessels, and when these Diverticular disease High-fiber diet is the best safeguard By Karin M. Rettig, MD
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The publisher’s sale of this reprint does not constitute or imply any endorsement or sponsorship of any project, service, company or organization.Minnesota Physician Reprints (612-728-8600) • 2812 East 26th Street, Mpls., MN 55406. Do not edit or alter reprints. Reproductions not permitted.
MINNESOTA
Your Guide to Consumer Information
December 2008 • Volume 6 Number 12
Diverticular disease is the fifthmost important gastrointesti-nal condition in terms ofdirect and indirect health care costs inWestern countries. People with thiscondition usually have no symptoms,but complications can lead to hospitalization and rarely, death.Diverticulosis describes the presenceof several pocket-like protrusionsalong the colon wall. A single pocketis called a diverticulum. When thesepockets become inflamed or infected,the condition is referred to as diverti-culitis. Diverticular disease includesboth diverticulosis and diverticulitis.
Although diverticulosis is nowcommon in both men and women, it was virtually unknown in the previous century. The incidence ofdiverticular disease in westernizedcountries has increased from a rangeof 5 percent to 10 percent 80 yearsago to 35 percent to 50 percent today. It is increasingly common withadvancing age; it is estimated that up to 65 percent of people over 80years of age have this condition.
Diverticulosis progresses to diverticulitis in roughly 15 percent to25 percent of people with diverticulardisease. Nearly all diverticulitis ismild, and it usually responds well tomedical treatment.
Causes
Diverticular disease is more commonin developed countries, which suggeststhat lifestyle and environment signifi-cantly contribute to the developmentof this condition.
While specific triggers of divertic-ulitis are not known, the most impor-tant factor influencing the develop-ment of diverticulosis is diet. It isknown that low dietary fiber increasesthe chance of developing diverticulo-sis. Diverticulosis is rare in underde-veloped countries unless a westernizeddiet has been adopted. Lifelong vege-tarians also seem to have fewer diver-ticula, most likely because fruits andvegetables are important sources offiber and represent the majority of thevegetarian diet. A low-fiber diet caus-es constipation—small, hard stoolsthat put pressure on colon walls,pushing the walls outward. Frequent,abnormal contractions or spasms ofthe colon wall are found in this condi-tion and also increase colonic wallpressure. Over time, weaknesses in thewalls develop into diverticula. Dietaryfiber counteracts this process by soft-ening stools. Softer stool passesthrough the colon faster, thus limitingpressure on the walls of the colon.
Other factors influencing divertic-ulosis may include physical activity,obesity, and genetic predisposition.
However, how exercise prevents diver-ticulosis is unknown, and evidence forthe role of obesity is controversial.
Symptoms
Diverticulosis usually has no symp-toms and is most often found inciden-tally. Mild symptoms can includeoccasional bloating; flatulence; irregu-lar stools; hard, pellet-like stools; orattacks of diarrhea. Major complica-tions of diverticulosis include divertic-ulitis and diverticular bleeding.
The most common symptom ofdiverticulitis is pain in the left lowerabdomen; the severity of symptomsdepends on the extent and degree of inflammation. Nausea, vomiting,fever, constipation, diarrhea, problemswith urination, and rectal bleedingcan also occur. Diverticulitis can rangefrom mild, single attacks to severe,recurrent disease. Complicated diverti-culitis involves the formation of anabscess (collection of pus), a fistula(an abnormal tract between organs),obstruction or blockage of the colon,perforation (a hole in the colon), orsepsis (overwhelming infection spread-ing throughout the body). Cases likethese require hospitalization.
Diverticular bleeding occurs in 3 percent to 5 percent of people withdiverticulosis. Diverticula are formednear blood vessels, and when these
Diverticular diseaseHigh-fiber diet is the best safeguard
By Karin M. Rettig, MD
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vessels are affected by constantinflammation over time, they can rupture into the colon. Mostoften the bleeding is painless andstops spontaneously. Bleeding thatcontinues or is massive requireshospitalization.
Diagnosis
Radiologic evaluation of the colonis the easiest way to diagnosediverticular disease. A computertomographic (CT) scan or mag-netic resonance imaging (MRI)scan can easily find diverticulosis. These imaging studies provide atwo-dimensional picture of theabdomen in cross-section. A newertype of CT scan, sometimes calleda “virtual colonoscopy,” allowsphysicians to view the colon inthree dimensions.
A barium enema, which uses a contrast dye, can be placed inthe colon to enhance its outline on a plain x-ray.
Finally, doctors can perform a colonoscopy or a flexible sigmoi-doscopy, using a flexible tube witha light and a camera to lookdirectly at the colon lining. Acolonoscopy allows examinationof the entire large intestine; a flexible sigmoidoscopy examines only the lower third.
Treatment
Diverticulosis without symptoms doesnot require treatment.
Simple diverticulitis can be treatedat home with oral antibiotics, rest,and a clear liquid diet for a few days.
Complicated diverticulitis requireshospitalization, antibiotics and fluids by vein, and possibly surgery.Improvement generally occurs in most patients within 48 to 72 hoursof admission.
Diverticular bleeding usually stopswithout intervention, but angiographyis used to stop serious blood loss. Thistest, done by a radiologist, involves
injecting contrast dye into the colonvessels, much as cardiologists do toexamine heart vessels. Substances can then be injected to “plug up” the bleeding vessel. This technique is successful 85 percent of the time, butwhen it fails to control blood loss,surgery is needed.
Surgery is reserved for very severe cases or for people with multi-ple episodes. Between 15 percent and30 percent of patients admitted to the hospital with acute, complicateddiverticulitis eventually need surgery.Emergency surgery is sometimes needed for severe, acute attacks. Forchronic, recurrent disease, the timingof surgery is controversial. TheAmerican Society of Colon and RectalSurgeons suggests that this decision be
made on a case-by-case basis.Surgery is usually considered whenthere have been three or four acuteattacks.
Prevention
Once diverticulosis is present, itdoes not go away. The best way to prevent further formation ofdiverticula is to follow a high-fiberdiet that includes fruits, vegetables,and whole grains. The AmericanDietetic Association (ADA) recom-mends consuming 20 to 35 gramsof fiber daily. While it is possibleto obtain this much fiber in food,the ADA says most Americans con-sume only about half the recom-mended amount. An easy way toincrease fiber consumption is toadd fiber supplements such as psyllium (Metamucil) and methyl-cellulose (Citrucel) to the diet.These preparations offer between 3 and 4 grams of fiber per dose.
Health providers frequentlyadvise patients to avoid nuts andseeds, with the idea that thesemight become lodged in the diver-ticula and lead to diverticulitis.However, there is no evidence thatthis occurs. A recent study showedthat nuts, corn, and popcorn con-
sumption did not lead to increasedepisodes of diverticulitis and diverti-cular bleeding. In fact, those who atenuts at least twice a week had a 20percent lower risk of diverticulitis,and those who ate popcorn twiceweekly had a 28 percent lower risk.
A combined strategy of increasingfiber intake, engaging in moderateexercise, maintaining a healthyweight, and drinking enough waterdaily will contribute to long-termcolon health.
Karin M. Rettig, MD, is a board-certifiedgastroenterologist with MinnesotaGastroenterology, P.A., in Maplewood.Her special interests are general gastroen-terology, small bowel capsule endoscopy,and gastrointestinal cancers.
American College ofGastroenterologyP.O. Box 342260Bethesda, MD 20827301-263-9025www.acg.gi.org
AmericanGastroenterologicalAssociation4930 Del Ray AvenueBethesda, MD 20814301-654-5920www.gastro.org
American Society of Colonand Rectal Surgeons85 West Algonquin Road,Suite 550Arlington Heights, IL 60005847-290-9203www.fascrs.org
MinnesotaGastroenterology2250 University Avenue WestSuite 423 SouthSt. Paul, MN 55114612-871-1145www.mngastro.com
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