Diverticulosis and Diverticulitis

National Digestive Diseases Information Clearinghouse

What are diverticulosis and diverticulitis? Many people have small pouches in the lin­ ing of the colon, or large intestine, that bulge Colon (large intestine) U.S. Department of Health and outward through weak spots. Each pouch is Human Services called a diverticulum. Multiple pouches are called diverticula. The condition of having NATIONAL diverticula is called diverticulosis. About INSTITUTES OF HEALTH 10 percent of Americans older than 40 have diverticulosis.1 The condition becomes more common as people age. About half of all people older than 60 have diverticulosis.2 Diverticula are most common in the lower portion of the large intestine, called the

sigmoid colon. When the pouches become Diverticula inflamed, the condition is called diverticulitis. Ten to 25 percent of people with diverticulosis get diverticulitis.3 Diverticulosis and divertic­ Many people have small pouches in their colon that ulitis together are called diverticular disease. bulge outward through weak spots. Each pouch is called a diverticulum. Multiple pouches are called diverticula. The condition of having diverticula is What are the symptoms called diverticulosis. of diverticulosis and diverticulitis? not always mean a person has diverticulosis. Diverticulosis People with chronic symptoms should visit Most people with diverticulosis do not have their doctor or health care provider. any discomfort or symptoms. However, Diverticulitis some people may experience crampy pain or discomfort in the lower abdomen, bloating, The most common symptom of diverticulitis and constipation. Other conditions such as is abdominal pain. The most common sign irritable bowel syndrome and stomach ulcers on examination is tenderness in the lower cause similar problems, so the symptoms do left side of the abdomen. Usually, the pain is severe and comes on suddenly, but it can also be mild and become worse over several days. 1Bogardus ST. What do we know about diverticular disease? A brief overview. Journal of Clinical The intensity of the pain can fluctuate. A per­ Gastroenterology. 2006;40:S108–S111. son may experience cramping, nausea, vomit­ 2Ibid. ing, fever, chills, or a change in bowel habits. 3Ibid. What are the complications Infected diverticula may develop perfora­ tions. Sometimes the perforations leak pus of diverticulitis? out of the colon and form a large abscess Diverticulitis can lead to bleeding; infections; in the abdominal cavity, a condition called small tears, called perforations; or blockages peritonitis. A person with peritonitis may be in the colon. These complications always extremely ill with nausea, vomiting, fever, and require treatment to prevent them from pro­ severe abdominal tenderness. The condi­ gressing and causing serious illness. tion requires immediate surgery to clean the abdominal cavity and remove the damaged Bleeding part of the colon. Without prompt treatment, Rectal bleeding from diverticula is a rare peritonitis can be fatal. complication. Doctors believe the bleeding is caused by a small blood vessel in a diver­ Fistula ticulum that weakens and then bursts. When A fistula is an abnormal connection of tissue diverticula bleed, blood may appear in the between two organs or between an organ and toilet or in the stool. Bleeding can be severe, the skin. When damaged tissues come into but it may stop by itself and not require treat­ contact with each other during infection, they ment. A person who has bleeding from the sometimes stick together. If they heal that rectum—even a small amount—should see way, a fistula may form. When diverticulitis- a doctor right away. Often, colonoscopy is related infection spreads outside the colon, used to identify the site of bleeding and stop the colon’s tissue may stick to nearby tissues. the bleeding. Sometimes the doctor injects The organs usually involved are the bladder, dye into an artery—a procedure called small intestine, and skin. angiography—to identify and treat diver­ The most common type of fi stula occurs ticular bleeding. If the bleeding does not between the bladder and the colon. This stop, surgery may be necessary to remove the type of fistula affects men more often than involved portion of the colon. women. It can result in a severe, long-lasting Abscess, Perforation, and infection of the urinary tract. The problem can be corrected with surgery to remove the Peritonitis fistula and the affected part of the colon. Diverticulitis may lead to infection, which often clears up after a few days of treatment Intestinal Obstruction with antibiotics. If the infection gets worse, Scarring caused by infection may lead to par­ an abscess may form in the wall of the colon. tial or total blockage of the intestine, called An abscess is a localized collection of pus intestinal obstruction. When the intestine is that may cause swelling and destroy tissue. blocked, the colon is unable to move bowel If the abscess is small and remains in the wall contents normally. If the intestine is com­ of the colon, it may clear up after treatment pletely blocked, emergency surgery is neces­ with antibiotics. If the abscess does not clear sary. Partial blockage is not an emergency, up with antibiotics, the doctor may need to so the surgery to correct it can be planned. drain it using a catheter—a small tube— placed into the abscess through the skin. After giving the patient numbing medicine, the doctor inserts the needle through the skin until reaching the abscess and then drains the fluid through the catheter. This process may be guided by sonography or x ray.

2 Diverticulosis and Diverticulitis What causes diverticular How is diverticular disease disease? diagnosed? Although not proven, the dominant theory To diagnose diverticular disease, the doctor is that a low-fiber diet causes diverticular asks about medical history, does a physical disease. The disease was first noticed in the exam, and may perform one or more diag­ United States in the early 1900s, around nostic tests. Because most people do not the time processed foods were introduced have symptoms, diverticulosis is often found into the American diet. Consumption of through tests ordered for another ailment. processed foods greatly reduced Americans’ For example, diverticulosis is often found fiber intake. during a colonoscopy done to screen for cancer or polyps or to evaluate complaints of Diverticular disease is common in developed pain or rectal bleeding. or industrialized countries—particularly the United States, England, and Austra­ When taking a medical history, the doc­ lia—where low-fiber diets are consumed. tor may ask about bowel habits, pain, other The disease is rare in Asia and Africa, where symptoms, diet, and medications. The most people eat high-fi ber diets. physical exam usually involves a digital rectal exam. To perform this test, the doctor inserts Fiber is the part of fruits, vegetables, and a gloved, lubricated finger into the rectum to grains that the body cannot digest. Some detect tenderness, blockage, or blood. The fiber, called soluble fiber, dissolves easily in doctor may check stool for signs of bleeding water. It takes on a soft, jelly-like texture in and test blood for signs of infection. If diver­ the intestines. Insoluble fiber passes almost ticulitis is suspected, the doctor may order unchanged through the intestines. Both one of the following radiologic tests: kinds of fiber help prevent constipation by making stools soft and easy to pass. • Abdominal ultrasound. Sound waves are sent toward the colon through Constipation—or hard stool—may cause a handheld device that a technician people to strain when passing stool during glides over the abdomen. The sound a bowel movement. Straining may cause waves bounce off the colon and other increased pressure in the colon, which may organs, and their echoes make electrical cause the colon lining to bulge out through impulses that create a picture—called weak spots in the colon wall. These bulges a sonogram—on a video monitor. If are diverticula. the diverticula are inflamed, the sound Lack of exercise also may be associated waves will also bounce off of them, with a greater risk of forming diverticula, showing their location. although the reasons for this are not well • Computerized tomography (CT) scan. understood. The CT scan is a noninvasive x ray that Doctors are not certain what causes divertic­ produces cross-section images of the ula to become inflamed. The infl ammation body. The doctor may inject dye into may begin when bacteria or stool are caught a vein and the person may be given a in the diverticula. An attack of diverticulitis similar mixture to swallow. The person can develop suddenly and without warning. lies on a table that slides into a donut- shaped machine. The dye helps to show complications of diverticulitis such as perforations and abscesses.

3 Diverticulosis and Diverticulitis How is diverticular disease data support this treatment measure. Eat­ ing a high-fiber diet is the only require­ treated? ment highly emphasized across the medical A high-fiber diet and pain medications help literature. Eliminating specific foods is not relieve symptoms in most cases of diverticu­ necessary. The seeds in tomatoes, zucchini, losis. Uncomplicated diverticulitis with mild cucumbers, strawberries, and raspberries, as symptoms usually requires the person to rest, well as poppy seeds, are generally considered take oral antibiotics, and be on a liquid diet harmless. People differ in the amounts and for a period of time. Sometimes an attack types of foods they can eat. Decisions about of diverticulitis is serious enough to require diet should be made based on what works a hospital stay, intravenous (IV) antibiotics, best for each person. Keeping a food diary and possibly surgery. may help identify what foods may cause Diverticulosis symptoms. Increasing the amount of fiber in the diet If cramps, bloating, and constipation are may reduce symptoms of diverticulosis and problems, the doctor may prescribe a short prevent complications such as diverticulitis. course of pain medication. However, some Fiber keeps stool soft and lowers pressure pain medications actually cause constipation. inside the colon so that bowel contents can Diverticulitis move through easily. The American Dietetic Association recommends consuming Treatment for diverticulitis focuses on clear­ 20 to 35 grams of fiber each day. The table ing up the inflammation and infection, rest­ “What foods have fiber?” shows the amount ing the colon, and preventing or minimizing of fiber in some foods that a person can eas­ complications. ily add to the diet. Depending on the severity of symptoms, The doctor may also recommend taking the doctor may recommend bed rest, oral a fiber product such as methylcellulose antibiotics, a pain reliever, and a liquid diet. (Citrucel) or psyllium (Metamucil) one to If symptoms ease after a few days, the doctor three times a day. These products are avail­ will recommend gradually increasing the able in powder, pills, or wafers, and provide amount of high-fiber foods in the diet. 2 to 3.5 grams of fiber per dose. Fiber prod­ Severe cases of diverticulitis with acute ucts should be taken with at least 8 ounces pain and complications will likely require of water. a hospital stay. Most cases of severe diver­ Avoidance of nuts, popcorn, and sunfl ower, ticulitis are treated with IV antibiotics and pumpkin, caraway, and sesame seeds has a few days without food or drink to help the been recommended by physicians out of fear colon rest. In some cases, surgery may be that food particles could enter, block, or irri- necessary. tate the diverticula. However, no scientifi c

4 Diverticulosis and Diverticulitis What foods have fiber? Examples of foods that have fi ber include

Breads, cereals, and beans Fiber 1/2 cup of navy beans 9.5 grams 1/2 cup of kidney beans 8.2 grams 1/2 cup of black beans 7.5 grams

Whole-grain cereal, cold 1/2 cup of All-Bran 9.6 grams 3/4 cup of Total 2.4 grams 3/4 cup of Post Bran Flakes 5.3 grams

1 packet of whole-grain cereal, hot 3.0 grams (oatmeal, Wheatena)

1 whole-wheat English muffi n 4.4 grams

Fruits 1 medium apple, with skin 3.3 grams 1 medium pear, with skin 4.3 grams 1/2 cup of raspberries 4.0 grams 1/2 cup of stewed prunes 3.8 grams

Vegetables 1/2 cup of winter squash 2.9 grams 1 medium sweet potato with skin 4.8 grams 1/2 cup of green peas 4.4 grams 1 medium potato with skin 3.8 grams 1/2 cup of mixed vegetables 4.0 grams 1 cup of caulifl ower 2.5 grams 1/2 cup of spinach 3.5 grams 1/2 cup of turnip greens 2.5 grams

Source: U.S. Department of Agriculture and U.S. Department of Health and Human Services, Dietary Guidelines for Americans, 2005.

5 Diverticulosis and Diverticulitis When is surgery necessary for diverticulitis? Points to Remember If symptoms of diverticulitis are frequent, or • Diverticulosis occurs when small the patient does not respond to antibiotics pouches called diverticula bulge out­ and resting the colon, the doctor may advise ward through weak spots in the colon, surgery. The surgeon removes the affected or large intestine. part of the colon and joins the remaining • Most people with diverticulosis never sections. This type of surgery—called colon have any discomfort or symptoms. resection—aims to prevent complications • Diverticula form when pressure builds and future diverticulitis. The doctor may inside the colon wall, usually because also recommend surgery for complica­ of constipation. tions such as a fistula or partial intestinal obstruction. • The most likely cause of diverticulosis is a low-fiber diet because it increases Immediate surgery may be necessary when constipation and pressure inside the the patient has other complications, such colon. as perforation, a large abscess, peritonitis, complete intestinal obstruction, or severe • For most people with diverticulosis, bleeding. In these cases, two surgeries may eating a high-fiber diet is the only be needed because it is not safe to rejoin the treatment needed. colon right away. During the fi rst surgery, • Fiber intake can be increased by eat­ the surgeon cleans the infected abdominal ing whole-grain breads and cereals; cavity, removes the portion of the affected fruits like apples and pears; vegetables colon, and performs a temporary colostomy, like peas, spinach, and squash; and creating an opening, or stoma, in the abdo­ starchy vegetables like kidney and men. The end of the colon is connected to black beans. the opening to allow normal eating while • Diverticulitis occurs when the healing occurs. Stool is collected in a pouch pouches become inflamed and cause attached to the stoma. In the second surgery pain and tenderness in the lower left several months later, the surgeon rejoins the side of the abdomen. ends of the colon and closes the stoma. • Diverticulitis can lead to bleeding; infections; small tears, called perfo­ rations; or blockages in the colon. These complications always require treatment to prevent them from pro­ gressing and causing serious illness. • Severe cases of diverticulitis with acute pain and complications will likely require a hospital stay. When a person has complications or does not respond to medication, surgery may be necessary.

6 Diverticulosis and Diverticulitis Hope through Research For More Information The National Institute of Diabetes and American College of Gastroenterology Digestive and Kidney Diseases and the P.O. Box 342260 National Cancer Institute sponsor research Bethesda, MD 20827–2260 programs to investigate diverticulosis and Phone: 301–263–9000 diverticulitis. Fax: 301–263–9025 Internet: www.acg.gi.org Investigation continues in several areas, including American Gastroenterological • a possible link between diverticular dis­ Association ease and inflammatory bowel disease 4930 Del Ray Avenue • the management of recurrent diverticu­ Bethesda, MD 20814 lar disease Phone: 301–654–2055 Fax: 301–654–5920 • the use of probiotics in the prevention Email: [email protected] and treatment of diverticular disease Internet: www.gastro.org • indications for surgery for uncompli­ cated diverticulitis American Society of Colon and Rectal Surgeons Participants in clinical trials can play 85 West Algonquin Road, Suite 550 a more active role in their own health care, Arlington Heights, IL 60005 gain access to new research treatments Phone: 847–290–9184 before they are widely available, and help Fax: 847–290–9203 others by contributing to medical research. Email: [email protected] For information about current studies, visit Internet: www.fascrs.org www.ClinicalTrials.gov. International Foundation for Functional Gastrointestinal Disorders P.O. Box 170864 Milwaukee, WI 53217–8076 Phone: 1–888–964–2001 or 414–964–1799 Fax: 414–964–7176 Email: [email protected] Internet: www.iffgd.org

7 Diverticulosis and Diverticulitis You may also find additional information about this National Digestive Diseases topic by visiting MedlinePlus at www.medlineplus.gov. Information Clearinghouse This publication may contain information about medications. When prepared, this publication 2 Information Way included the most current information available. Bethesda, MD 20892–3570 For updates or for questions about any medications, Phone: 1–800–891–5389 contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (1–888–463–6332) TTY: 1–866–569–1162 or visit www.fda.gov. Consult your doctor for more Fax: 703–738–4929 information. Email: [email protected] Internet: www.digestive.niddk.nih.gov The National Digestive Diseases Information The U.S. Government does not endorse or favor any Clearinghouse (NDDIC) is a service of the specific commercial product or company. Trade, National Institute of Diabetes and Digestive and proprietary, or company names appearing in this Kidney Diseases (NIDDK). The NIDDK is part document are used only because they are considered necessary in the context of the information provided. of the National Institutes of Health of the U.S. If a product is not mentioned, the omission does not Department of Health and Human Services. mean or imply that the product is unsatisfactory. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases. Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scien- tists and outside experts. This publication was reviewed by Lawrence R. Schiller, M.D., Baylor University Medical Center at Dallas.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health

NIH Publication No. 08–1163 July 2008