Diverticular Disease

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

Definition

Diverticular disease is a common condition that affects the digestive system, primarily the large intestine, also known as the colon. It refers to the presence of small, bulging pouches called diverticula that develop along the inner lining of the colon. Although these pockets can form throughout the colon, they are most commonly found in the lower part of the large intestine.
There are two main forms of diverticular disease: diverticulosis and diverticulitis.

Aetiology

1. Age

One significant risk factor for diverticular disease is advancing age. The incidence of this condition is relatively low among younger individuals but increases significantly with age. It is believed that the progressive weakening of the colon wall with age may play a role in the formation of diverticula.

2. Low-Fiber Diet

Dietary habits are thought to play a crucial role in the development of diverticular disease. A primary risk factor is a diet low in fibre content. A lack of dietary fibre can lead to constipation and hardening of the stool, which in turn increases pressure within the colon. This increased pressure may promote the formation of diverticula over time.

3. Lack of Physical Activity

A sedentary lifestyle and lack of physical activity have been linked to an increased risk of developing diverticular disease. Regular exercise helps maintain healthy bowel function and reduces the likelihood of constipation. Physical activity also promotes overall colon health by improving blood circulation and reducing inflammation.

4. Genetic Predisposition

Research suggests that genetic factors may contribute to the development of diverticular disease. Individuals with a family history of this condition may have a higher risk of developing it themselves. However, the specific genes involved and the exact mechanisms by which they influence diverticular disease are still being investigated.

5. Obesity and Abdominal Pressure

Obesity and increased abdominal pressure are associated with an elevated risk of diverticular disease. Being overweight or obese places excess stress on the walls of the colon and can contribute to the development of diverticula. Similarly, chronic conditions such as chronic obstructive pulmonary disease (COPD) that result in increased abdominal pressure may also increase the risk.

6. Smoking and Alcohol Consumption

Both smoking and heavy alcohol consumption have been identified as potential risk factors for diverticular disease. These lifestyle habits can contribute to inflammation and damage to the colon lining, making it more susceptible to diverticula formation.

7. Medications and Medical Conditions

Certain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids, have been associated with an increased risk of diverticular disease. Additionally, medical conditions such as connective tissue disorders and inflammatory bowel disease (IBD) may predispose individuals to develop diverticula.

While the aetiology of diverticular disease is multifactorial and complex, understanding the contributing factors can help individuals adopt preventive measures. Maintaining a high-fibre diet, engaging in regular physical activity, and avoiding smoking and excessive alcohol consumption are all steps that can reduce the risk of developing this condition. Moreover, individuals with a family history of diverticular disease may benefit from early screening and close monitoring. By addressing these factors, it is possible to mitigate the risk and potentially prevent the onset of diverticular disease.

Pathophysiology

1. Diverticulosis: This is the milder form of the condition, in which diverticula are present but do not cause any noticeable symptoms or complications. It is estimated that around 50% of individuals over the age of 60 have diverticulosis. Often, people are unaware of their condition until they undergo a routine colonoscopy or experience complications related to diverticulosis.

2. Diverticulitis: This is a more severe form of diverticular disease. It occurs when the diverticula becomes inflamed or infected. The exact cause of diverticulitis is not fully understood, but it is believed to result from stool or bacteria getting trapped within the diverticula and causing an infection.

The pathophysiology of diverticular disease involves a combination of structural and functional changes in the colonic wall, primarily influenced by dietary and lifestyle factors. The exact cause of diverticula formation is not fully understood, but it is commonly believed to be associated with increased colonic pressure and weakness in the bowel wall.

One significant factor leading to diverticula formation is increased intraluminal pressure within the colon. This can be observed in individuals with a low-fiber diet, which leads to stool hardening and increased resistance during bowel movements. The increased pressure required to expel stool creates areas of weakness in the colonic wall, particularly where the blood vessels penetrate. Over time, these weak points, also known as colonic diverticula, protrude outward, causing the formation of diverticula.

Moreover, the role of connective tissue alterations in the colonic wall cannot be neglected. There is evidence suggesting that changes in the collagen and elastin composition of the colonic wall contribute to the development of diverticula. Impaired collagen synthesis and an imbalance between collagen and elastin degradation in the connective tissue disrupt the structural integrity of the colon, rendering it more susceptible to the formation of diverticula.

Diverticulosis itself is usually asymptomatic and often goes unnoticed. However, complications can arise when diverticula becomes inflamed or infected, leading to diverticulitis. The inflammation occurs when bacteria within the diverticula multiply and cause microperforations or microabscesses. This triggers an immune response, resulting in the recruitment of inflammatory cells and subsequent inflammation of the colon wall. In severe cases, complications like abscesses, perforation, or fistula formation may occur.

Risk factors

see aetiology

Sign and symptoms

1. Diverticulosis

Many individuals with diverticular disease exhibit a condition called diverticulosis, which refers to the presence of diverticula in the colon wall without inflammation. In diverticulosis, individuals often do not experience any apparent symptoms. As a result, most cases are only discovered incidentally during routine diagnostic procedures such as an imaging study or colonoscopy.

2. Diverticulitis

Diverticulitis, on the other hand, occurs when the diverticula becomes inflamed or infected. This condition is commonly associated with the following signs and symptoms:

a. Abdominal pain: One of the hallmark symptoms of diverticulitis is localised abdominal pain, typically on the lower left side. The pain can range from mild to severe and may persist for several days. Some individuals may also experience a change in pain intensity with movement or eating.

b. Fever: In cases of diverticulitis, the body's immune response to infection often leads to an elevation of body temperature. Fever can indicate an active inflammatory process within the affected diverticula.

c. Change in bowel habits: Diverticulitis can cause alterations in bowel movements, such as diarrhoea or constipation. Some individuals may experience alternating episodes of both.

d. Nausea and vomiting: When diverticulitis becomes severe, it may cause nausea and vomiting, as the body tries to expel the irritants and pathogens causing the inflammation.

Diagnosis and investigations

1. History and Physical Examination:

A PA should inquire about symptoms, durations, and any potential risk factors. They may also palpate the abdomen for tenderness or abnormal masses.

2. Blood Tests:

Elevated white blood cell count (indicative of infection), elevated C-reactive protein (indicating inflammation), and anaemia may suggest diverticulitis or complications.

3. Imaging Studies:

Colonoscopy: Considered the gold standard for evaluating the colon, a colonoscopy involves inserting a flexible tube with a camera into the rectum to examine the entire colon. This helps the doctor identify diverticula, assess their severity, and rule out other conditions such as polyps or colorectal cancer.
Computerised Tomography (CT) Scan: CT scans provide detailed cross-sectional images of the colon and are commonly used to diagnose diverticulitis. They can identify inflamed diverticula, abscesses, fistulas, or other complications associated with diverticular disease.

4. Stool Analysis:
Stool analysis (FIT test or Faecal calprotectin) may be conducted to rule out other causes of gastrointestinal symptoms and to identify any signs of infection or inflammation. It can also detect the presence of blood in the stool, which may suggest complications such as diverticular bleeding.

Management

Dietary Changes:

High-fibre diet: Consuming a diet rich in fibre helps regulate bowel movements and prevents constipation, reducing the strain on the colon. This includes incorporating fruits, vegetables, whole grains, and legumes into regular meals.
Fluid intake: Adequate fluid consumption is essential to maintain hydration and promote proper stool consistency. Drinking enough water and other fluids throughout the day prevents constipation and facilitates regular bowel movements.
Avoiding triggering foods: Individuals with diverticular disease may need to identify and avoid specific foods that exacerbate symptoms. This typically includes foods that are hard to digest or high in refined sugars and unhealthy fats.

Medications:

Pain management: Over-the-counter pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, can help manage mild pain associated with diverticulitis.
Antibiotics: In cases of acute diverticulitis, where infection is present, antibiotics are often prescribed to combat the bacterial infection and reduce inflammation.
Fibre supplements: If dietary changes are insufficient, fibre supplements like psyllium husk or methylcellulose may be recommended to promote regular bowel movements.
Probiotics: In some instances, probiotics may be prescribed to restore a healthy balance of gut bacteria, which can alleviate symptoms and improve overall gastrointestinal health.

Lifestyle Modifications:

Regular exercise: Engaging in regular physical activity helps maintain healthy bowel function, reduces stress, and contributes to overall well-being.
Smoking cessation: Quitting smoking is important for individuals with diverticular disease as smoking may worsen symptoms and increase the risk of complications.
Stress management: Stress can exacerbate symptoms and disrupt bowel function. Adopting stress management techniques such as meditation, deep breathing exercises, or engaging in hobbies can be beneficial.

Surgical Intervention: