Crohn’s Disease
October 25, 2017
Drug-induced Hepatitis
October 25, 2017
Show all

Diverticula (Diverticulosis, Diverticular Disease & Diverticulitis)

What do diverticula imply?

A diverticulum is a small pouch with a narrow neck that sticks out from (protrudes from) the wall of the gut (intestine). Diverticula means more than one diverticulum. They can develop on any part of the gut, but usually occur in the colon (sometimes called the large bowel or large intestine). They most commonly develop in the section of the colon leading towards the back passage (rectum). This is where the stools (faeces) are becoming more solid. This is on the left-hand side of the tummy (abdomen). Several diverticula may develop over time. Some people eventually develop many diverticula.

People prone to diverticula

Diverticula are common. They become more common with increasing age. About half of all people have diverticula by the time they are 50 years old. Nearly 7 in 10 have diverticula by the time they are 80 years old.

Triggers of diverticula

The reason why diverticula develop is probably related to not eating enough fibre. Fibre is the part of food that is not digested.

Stools (faeces) are moved by the gut (intestine) along with gentle squeezes of its muscular wall. The stools tend to be drier, smaller, and more difficult to move along if one doesn’t eat much fibre. One’s gut muscles have to work harder if there is too little fibre in the gut. High pressure may develop in parts of one’s gut when it squeezes hard stools.

The increased pressure may push the inner lining of a small area of one’s gut through the muscle wall to form a small diverticulum.

Surfacing of diverticula and troubles caused

When diverticulosis doesn’t cause any symptoms.

In about 3 in 4 people who develop diverticula it does not cause symptoms. The term diverticulosis means that diverticula are present, but do not cause any symptoms or problems. In most cases, the condition will not be known about as there are no symptoms. Sometimes diverticula are discovered as an incidental finding if one is having investigations such as colonoscopy or barium enema for other reasons.

Diverticular disease

This term is used when diverticula cause intermittent, lower tummy (abdominal) pain or bloating (without swelling (inflammation) or infection – discussed later). The pain is usually crampy and tends to come and go. The pain is most commonly in the lower left part of the tummy (abdomen). You may get ease from pain and bloating by going to the toilet to pass stools (faeces). Some people develop diarrhoea or constipation, and some people pass mucus with their stools. It is not clear how diverticula cause these symptoms.

Symptoms of diverticular disease can be similar to those that occur with a condition called irritable bowel syndrome (IBS). However, IBS usually affects younger adults. However, in some cases it is difficult to tell if symptoms are due to diverticular disease or to IBS.

A diagnosis of diverticular disease is usually made by confirming the presence of diverticula and by ruling out other causes of the symptoms.

It must be noted that the symptoms of diverticular disease, especially if they start in an older person, can also be similar to those of early bowel cancer.  Therefore, one should tell a doctor if you develop these symptoms, as some tests may need to be arranged. For example,  colonoscopy may be advised. To carry out this test, a doctor uses a special flexible telescope to look into the bowel. This can confirm the presence of diverticula, and rule out bowel cancer.

Diverticulitis

Diverticulitis is a condition where one or more of the diverticula become inflamed and infected. This may occur if some faeces get trapped and stagnate in a diverticulum. Germs (bacteria) in the trapped faeces may then multiply and cause infection. About 1 in 5 people with diverticula develop a bout of diverticulitis at some stage. Some people have recurring bouts of diverticulitis. Symptoms of diverticulitis include:

High temperature (fever). Constipation or diarrhoea.

A constant pain in the abdomen. It is most commonly in the lower left side of the abdomen, but can occur in any part of the abdomen.

Feeling sick (nauseated) or being sick (vomiting

Some blood mixed with your stools.

Complications caused by diverticulitis

An infected diverticulum (diverticulitis) sometimes gets worse and causes complications. Possible complications include:

A hole (perforation) in the wall of the bowel that can lead to infection inside the abdomen (peritonitis)

A blockage (obstruction) of the colon.

A channel (fistula) that may form to other organs such as the bladder.

A collection of pus (abscess) that may form in the abdomen.

Surgery is usually needed to treat these serious but uncommon complications.

Bleeding

A diverticulum may occasionally bleed and you may pass some blood via your back passage (anus). The bleeding is usually abrupt and painless. The bleeding is due to a burst blood vessel that sometimes occurs in the wall of a diverticulum and so the amount of blood loss can be heavy. A very large bleed requiring an emergency blood transfusion occurs in some cases. However, the bleeding stops on its own in about 3 in 4 cases. Sometimes an operation is needed to stop the bleeding. Sometimes just a slight bleed occurs.

It is important that bleeding from the bowel (via one’s anus) should always be reported to a doctor. One should not assume bleeding is from a diverticulum. Other more serious conditions such as bowel cancer need to be ruled out.

Handling diverticulosis

As diverticulosis means diverticula with no symptoms, there is no need for any treatment.

However, a high-fibre diet is usually advised. A high-fibre diet is generally considered a good thing for everyone anyway – whether one has diverticula or not. Adults should aim to eat between 18 and 30 grams of fibre per day. Fibre helps to make larger and softer stools (faeces) and helps to prevent constipation. Also, a high-fibre diet may prevent further diverticula from forming. This may reduce the risk of developing problems in the future with diverticula, such as diverticulitis.

Treating diverticular disease

High-fibre diet, and possibly fibre supplements

A high-fibre diet is usually advised as it helps to keep stools (faeces) soft and bulky and reduces pressure on the colon. It can ease pain, bloating, constipation and diarrhoea and prevents hard stools becoming lodged within the pouches. It can also help to prevent the formation of further diverticula, which may reduce the risk of the condition getting any worse.

We need about 18 g of fibre each day, which should come from a variety of high-fibre foods. One may have symptoms of wind and bloating if one suddenly increases the amount of fibre in the diet. Any increase should be gradual to prevent this, and to allow one’s gut (intestine) to become used to the extra fibre. A useful guide is to make one change every few days. For example, start by swapping white bread for wholemeal bread, Introducing something new every few days, such as adding beans or extra vegetables to a casserole or bolognese, or having a piece of fruit for pudding.

High-fibre foods to include:

Wheat bran.

Whole grains, fruit and vegetables.

Beans, pulses and legumes.

Wholemeal or whole wheat bread and flour (for baking).

Wholegrain breakfast cereals.

Brown rice and whole wheat pasta.

Meeting the health recommendation of eating at least five fruit and vegetable portions each day will make sure that one is well on the way to getting plenty of fibre. A portion is about 80 g or what roughly fits in the palm of your hand. Apples, pears, oranges, blueberries, strawberries, broccoli, asparagus and dried figs are all excellent fibre sources.

Fibre supplements may be advised if a high-fibre diet does not ease symptoms. Several types are available at pharmacies, health food shops, or on prescription. A pharmacist will advise you. Although the effects of fibre supplements to ease symptoms may be seen in a few days, it may take as long as four weeks.

Important: some people have a different response to fibre than others. So it is very much trial and error as to what is most suitable for you. Some people report that a high-fibre diet or certain fibre supplements cause some persistent mild symptoms such as mild pains and bloating. This may be to do with the type of fibre being consumed. Insoluble fibre, found in cereals, wheat bran and nuts, may cause more wind and bloating. Eating a lot of bran-based foods or taking bran supplements can particularly aggravate symptoms in some people. Therefore, it may be helpful to have more soluble fibre (the type of fibre that can be dissolved in water), found mostly in fruit and vegetables. However, many foods contain both types of fibre, so when introducing a new high-fibre food, one must monitor the symptoms and adjust the diet accordingly.

Dietary sources of soluble fibre include oats, ispaghula (psyllium), nuts, flax seeds, lentils, beans, fruit and vegetables. A fibre supplement called ispaghula powder is also available from pharmacies and health food shops.

Insoluble fibre is chiefly found in corn (maize) bran, wheat bran, nuts and some fruit and vegetables.

Fluids

One should have lots to drink when one has a high-fibre diet or fibre supplements. One should aim to drink at least two litres (about 8-10 cups) per day. One should try to obtain the fluid intake mainly from water, but tea, coffee and herbal teas all contribute. Fizzy drinks and juice drinks contain a lot of sugar so try to limit these. If one wants to include fruit juice, one 150 ml glass each day only counts as a portion of fruit. Varieties that are 100% fruit juice and do not contain added sugar should be chosen.

Paracetamol

Paracetamol can ease pain if a high-fibre diet or fibre supplements do not help so much to ease pain. Other types of painkiller are not usually used for diverticular disease.

Diet for acute diverticulitis

During a flare-up, it is likely that one’s appetite will be poor. To prevent further irritation and to limit poorly digested materials passing through the colon, a bland, low-fibre diet may be most suitable. This should only be short-term. Once your symptoms have eased, gradually re-introduce normal, high-fibre foods into the diet. It can be helpful to introduce one food at a time and monitor symptoms to see what foods make symptoms worse.

High-fibre foods to avoid during flare-ups:

Beans, lentils and legumes

Fruit and vegetable skins. Nuts and seeds

Raw vegetables or raw/dried fruits such as apricots, raisins, dates, figs and berries.

Wholegrain products such as wholemeal bread, whole wheat pasta and brown rice, wholegrain

cereals and oats.

Low-fibre foods to include:

White grains such as bread, pasta, rice and noodles.

Plain cakes/crackers.

Potatoes with skins removed.

Low-fibre cereals such as Rice Krispies and corn flakes.

Milk and dairy products such as cheese and yoghurts.

Soft, ground/tender meats and fish (avoid gristly meats/bones).

Fats and oils – eg, olive oil, rapeseed oil, and butter.

Eggs.

Tofu.

Well-cooked/canned fruit and vegetables with seeds and skins removed.

If symptoms are severe, one’s doctor may advise a clear liquid diet for about two days to allow the colon to rest. Suitable clear liquids include:

Water.

Clear juices without pulp, such as apple, cranberry or grape juice.

Broths and clear soups.

Herbal teas, tea and coffee without milk.

Ice lollies.

Jelly.

As symptoms improve, one may introduce solid foods back into the diet. It may be best to introduce low-fibre foods initially, before gradually re-introducing a normal, high-fibre diet once symptoms have gone.

Mild symptoms

If you develop diverticulitis you will normally need a course of antibiotic medicine and be encouraged to drink plenty of clear fluids. One may be advised not to eat anything until symptoms settle. Once symptoms go, you can resume a normal diet. However, a high-fibre diet (as described above) is usually best.

Harsh or prolonged symptoms

If symptoms are severe then you may need to be admitted to hospital. You may be given antibiotics and fluids directly into a vein via a drip. You may need to have painkilling injections. You may also be admitted to hospital if the symptoms are not too severe but do not settle after 48 hours or so with antibiotic tablets.

Development of complexities

As mentioned earlier, some people with diverticulitis develop complications such as:

A collection of pus (an abscess).

Obstruction in the bowel.

A channel (fistula) that may form to other organs.

A tummy (abdominal) infection (peritonitis).

Surgery is usually needed to treat these serious but uncommon complications. For example, surgery is sometimes needed to drain an abscess or to remove a badly infected part of the colon.

Treatment of bleeding diverticula

As mentioned earlier, a large bleed requiring an emergency blood transfusion sometimes occurs in people with diverticula. However, the bleeding stops on its own in about 3 in 4 cases. Sometimes an operation is needed to stop the bleeding.

Conclusion

If one experiences a change in the pattern of your toilet habit, one must see a doctor, for example if a sudden change from one’s normal bowel habit to persisting constipation or diarrhoea, passing blood or mucus, or new pain is felt. Even if one is known to have diverticula, a change of symptoms may indicate a new and different gut (intestinal) problem.

Common in older people, diverticula of the colon generally have no symptoms, and in most cases no treatment is needed. However, a high-fibre diet is usually advised to help prevent complications. Pain and other symptoms are caused in some cases. Sometimes a diverticulum may bleed and cause a sudden, painless bleed from the back passage (anus), which can be heavy. In some cases, one or more diverticula become infected to cause diverticulitis. This can cause severe tummy (abdominal) pain and high temperature (fever). A course of antibiotics may be needed. A collection of pus (abscess) or a perforated bowel, are uncommon, but are serious complications caused by diverticulitis.