Clinical presentation
Seventy percent of persons with diverticulosis never develop significant symptoms. Some patients have mild, intermittent abdominal pain, bloating, flatulence, and altered defecation, although coexistence of irritable bowel syndrome is possible. Three-quarters of the remaining patients develop diverticulitis and one-quarter report hemorrhage.
Diagnostic investigation
On barium enema radiography, diverticula appear as contrast-filled colonic protrusions that may persist after evacuation. The presence of diverticula reduces the accuracy of barium enema radiography in detecting coexisting colonic neoplasia. Colonoscopy may reveal diverticular orifices, sigmoid tortuosity, and thickened folds consistent with prior diverticulitis.
Management and prevention
Therapy for symptomatic but uncomplicated diverticular disease relies on increased intake of dietary fiber or the use of fiber supplements. The role of low dietary fiber in the pathogenesis of diverticular disease is controversial. However, lack of vigorous physical activity is associated with diverticulosis, and obesity is associated with an increased risk of complications. Therefore, exercise and weight loss for overweight individuals are recommended.
Diverticulitis
Diverticulitis is symptomatic inflammation of a diverticulum and begins as peridiverticulitis caused by a microperforation of the colon. Diverticulitis can be classified as simple or complicated in presentation. The incidence of diverticulitis increases with age. Most cases of diverticulitis in westernized countries are left-sided but inflammation of diverticula at other sites, including the rectum and appendix, may occur.
Clinical presentation
Early manifestations of diverticulitis include pain and tenderness over the site of inflammation (usually in the lower abdomen or pelvis), nausea and vomiting, ileus, fever, a possible palpable mass, and tenderness or a mass effect on rectal examination. Complications of progressive inflammation include abscess, perforation, fistulization, and obstruction.
Differential diagnosis
The differential diagnosis of acute diverticulitis is broad and needs to be considered prior to embarking on therapy specific to diverticulitis. Acute appendicitis, Crohn’s disease, ischemic colitis, peptic ulcer disease, and pseudomembranous colitis can all present with symptoms similar to acute diverticulitis. Ectopic pregnancy and ovarian cysts, torsion or abscess should be suspected in female patients. Neoplasia, especially colorectal carcinoma, should also be considered, particularly in patients with weight loss or bleeding.
Diagnostic investigation
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