The large intestine is a long tube-like structure that stores and eliminates waste material. During normal lower intestinal function, the waste material (stool or feces) is slowly pushed along the large intestine to the rectum by the muscular bands in the colon. As a person ages, this continuous pressure can cause a bulging pocket of tissue or sac (called a diverticulum) that pushes out from the colon wall. More than one sac is called diverticula. Diverticula can occur throughout the large intestine, but are most commonly found near the end of the left intestine (called the sigmoid colon). The condition of having diverticula in the large intestine is called diverticulosis.
When a diverticulum ruptures or becomes infected, this condition is called diverticulitis. Diverticulitis develops when a mass of hardened waste matter (called a fecalith) forms in the pouch and reduces the blood supply to the thin walls of the pouch (by means of pressure against the wall), making them susceptible to infection by the bacteria of the colon.
Diverticulosis is rare before the age of 40, but the likelihood of developing this condition increases with passing decades. It is estimated that 30 percent of all people over the age of 45 have diverticulosis; at the age of 60, 50 percent of all people will develop this condition; and by the age of 85, 65 percent of all people will have diverticulosis.
Researchers believe that diverticulosis may be age related, genetically based and most importantly, caused by not enough fiber in the diet. A diet low in fiber can lead to small, hard stools that are difficult to pass and require more pressure to push them through the large intestine. Over time, these vigorous contractions in the large intestine push the inner intestinal lining outward, causing diverticula.
It is, perhaps, remarkable that so few people have complications of diverticulosis when compared with the number of people who have the condition. Still, complications do occur and they can be serious. Diverticulitis is the most common.
Diverticulosis is a disorder that may be preventable if treated early in life. At any stage, there is usually effective therapy available. Complication of divertiuclosis, can be readily diagnosed by the physician an effective therapy is available Working with the physician, prevention and treatment programs can be structured to obtain the best results for the patient.
Most people with diverticulosis have few or no symptoms. Doctors refer to diverticulosis with no symptoms as asymptomatic diverticulosis. For people who experience symptoms, the condition is called symptomatic diverticulosis. Symptomatic diverticulosis is categorized into three types - painful diverticulosis, inflammatory diverticulitis (inflamed and infected diverticula) and bleeding diverticulosis (the blood vessel in the wall of the diverticulum ruptures).
Symptoms of painful diverticulosis are:
Abdominal pain (usually located in the lower left abdomen) that subsides after a bowel movement or passing gas.
Constipation, followed by bouts of diarrhea.
Symptoms of inflammatory diverticulitis are:
Symptoms of bleeding diverticulosis are:
Urge to have a bowel movement.
Bright red blood clots and maroon-colored stool.
Sudden, mild cramps.
Causes and Risk factors:
Diverticula are believed to be caused by overly forceful contractions of the muscular wall of the large intestine. As areas of this wall spasm, they become weaker and weaker, allowing the inner lining to bulge through. The anatomically weakest areas of the intestinal wall occur next to blood vessels that course through the wall, so diverticula commonly occur in this location.
Diverticula are most common in the developed countries of the West (North America, Great Britain, northern and western Europe). This is thought to be due to the diet in these countries, which tends to be quite low in fiber. A diet low in fiber results in the production of smaller volumes inj stool. In order to move this smaller stool along the colon and out of the rectum, the colon must narrow itself significantly, and does so by contracting down forcefully. This causes an increase in pressure, which, over time, weakens the muscular wall of the intestine and allows diverticular pockets to develop.
The origin of giant diverticula development is not completely understood, although one theory involves gas repeatedly entering and becoming trapped in an already-existing diverticulum, causing stretching and expansion of that diverticulum.
Diverticulosis is often unsuspected and discovered by an x-ray or intestinal examination performed for an unrelated reason. The doctor may see the diverticula through a flexible tube (a colonoscope) that is inserted through the anus. Through this scope, the diverticula may be seen as dark passages leading out of the normal colon wall.
The doctor also may do a barium enema (an x-ray that reveals outpouchings in the walls of the colon). If rectal bleeding occurs, the doctor may take a special x-ray (an angiography). In this procedure, dye is injected into an artery that goes to the colon so that the site of the bleeding problem can be located
Laboratory tests have limited value in diagnosing small bowel diverticulosis. The following tests may be indicated.
CBC count: Elevated white blood cell (WBC) count may occur in diverticulitis. Hematocrit may drop following significant acute or chronic blood loss.
Chemistry: Liver chemistries, serum amylase, and lipase levels are performed only if indicated by clinical presentation to exclude other differential diagnoses.
Urinalysis: Urinalysis may be indicated to rule out urinary tract infection.
Blood culture: This is useful in patients presenting with fever, diverticulitis, intestinal perforation, and abscess to exclude septicemia.
Plain abdominal radiograph and/or chest radiograph demonstrates evidence of perforation, including air under the diaphragm; free peritoneal air; evidence of intestinal obstruction; or evidence of ileus, including multiple air-fluid levels and bowel dilatation.
Abdominal CT scan with contrast provides more information in complicated as well as uncomplicated cases. Phlegmon can be identified, especially in the retroperitoneal space, providing the initial clue to the possibility of small intestinal diverticular disease.
A double contrast barium meal and enteroclysis is useful in diagnosis but is contraindicated in acute diverticulitis or perforation.
Bleeding scan: This is used to determine the site of bleeding if the patient is hemodynamically stable. It is helpful in localizing bleeding sites, detecting bleeding as slow as 0.5 cc/min.
Mesenteric angiography: This is used for brisk hemorrhages to identify the bleeding site and offers the opportunity for mesenteric occlusion therapy.
If the patient has diverticulosis with no symptoms, no treatment is needed. Some doctors advise eating a special high fiber diet, consisting of fresh vegetables, fresh fruits, whole-grain breads, cereals and bran.
Additionally, adding a fiber supplement (such as Metamucil or Hydrocil) to the diet, and avoiding certain foods with small seeds, such as strawberries, raspberries, whole cranberries and nuts is helpful in treating diverticulosis.
Foods to Avoid: Conversely, there are foods to avoid that may aggravate diverticulosis, including nuts, popcorn, seeds and corn. Specific types of seeds to avoid include caraway, sunflower and pumpkin; the seeds in such foods as tomatoes, strawberries, raspberries, cucumbers or zucchini are considered safe, as are poppy seeds. It is believed that the potential harm of the seeds above is that they could become lodged in the diverticula and irritate or block it, leading to complications which may include diverticulitis. However, there is no scientific evidence to back up this theory. Patients who have diverticulosis are also encouraged to drink plenty of water to prevent constipation and reduce pressure in the intestine.
Patients experiencing bloating or abdominal pain may benefit from anti-spasmodic drugs, such as Librax, Bentyl, Donnotal and Levsin.
If this condition turns into diverticulitis, bedrest, antibiotics or hospitalization may be needed. The vast majority of patients will recover from diverticulitis without surgery. Sometimes, patients need surgery to drain an abscess that has resulted from a ruptured diverticulum and to remove that portion of the colon. Surgery is reserved for patients with very severe or multiple attacks. In such cases, the involved segment of colon can be removed and the colon can then be rejoined.
Complications of small bowel diverticulosis, such as massive bleeding or diverticulitis with perforation, require surgery. Diagnosis is seldom made preoperatively. The aim is to control complications when present and/or to prevent future complications. Simple diverticulectomy is most commonly used for symptomatic diverticulum or bleeding diverticulum of the duodenum. The diverticulum is simply excised, and the bowel is closed longitudinally or transversely, ensuring minimal luminal stenosis.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
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