There have been many changes over the years in the approach to diverticular disease (DD), even in the names used. Diverticular disease is the overall name. The presence of the grape-like diverticula on the outside of the colon results in a diagnosis of diverticulosis. Diverticulitis occurs when there is infection and inflammation of the diverticula but is often used when there are any symptoms caused by the disease.
Diverticulosis can have episodes of diverticulitis or complicated diverticulitis when problems such as bleeding, abscess, fistula or blockage need surgical treatment. This is a simplistic explanation of what might happen in DD in decreasing numbers, so that only a small fraction of people with DD ever need surgery. Any progression in the disease can stop and revert to symptomless diverticulosis at any time, some people with diverticulosis do not even know that they have it.
There has been confusion over many years about the symptoms with DD. Diverticulosis could give “painful DD” half a century ago. A later opinion was that pain could only be caused by diverticulitis. Later still, if there was pain with diverticulosis without infected diverticula, then that pain was IBS. There can be similarities in the symptoms from DD and IBS (1) but there are also differences (2) not least the changed structure of the colon with DD. Now the term “uncomplicated symptomatic DD” is used increasingly. This is really confusing for people and how DD is explained to them might depend on how long ago they were diagnosed. It is easier for them to call all symptoms of DD “diverticulitis”.
Pain, diarrhoea, constipation, bloating and flatulence are common symptoms with DD, giving people the dilemma of deciding if they are serious or not. If the symptoms come and go, move along the colon, are better after defaecation or passing flatulence and constipation or diarrhoea are short- lived and occasional, then dysfunction of colon movement is a likely cause. Infection and inflammation give more persistent symptoms. Pain may be severe and stay in the same place, there may be raised temperature and a person feels poorly all over. This can be quite sudden and “acute diverticulitis” requires medical treatment. Another type of diverticulitis is now recognised as chronic or smouldering (3) with regular low level symptoms. Sometimes painful inflammation, without infection of the diverticula, resembles IBD (Ulcerative colitis and Crohn’s disease) (4). The use of CT scanning now gives more accurate diagnosis of diverticulitis variants or the presence of complications enabling individual treatments (5).
Evidence now suggests that repeated episodes of diverticulitis can be common but rarely lead to complications. Conservative treatment (bland liquid diet, rest) and antibiotics can be effective and the need for surgery reduced (6,7). Differences of opinion on the use of antibiotics are confusing. Some researchers (8) found that antibiotics made no difference to the length of stay in a Swedish hospital or the recurrence of diverticulitis. Others advocate the occasional use of nonabsorbable antibiotics to reduce symptoms and diverticulitis episodes (9). People with diverticulitis are not always cared for in hospital or under their supervision. Many rely on their primary care provider to assess their individual risk.
“A fresh approach to a neglected disease” was the title of the Falk DD 179 symposium in 2011. It was noted that in the past, management of diverticulitis followed tradition rather than evidence-based medicine. Contributors to the symposium recognised the increased burden on hospitals and healthcare, the complexity of DD and variations in the effects on individuals. Some lifestyle factors are reported which might increase the risk of diverticulitis eg. obesity, dietary red meat, smoking and alcohol (10) and medication for other complaints (11). It is difficult to distinguish between causing symptoms and causing diverticulitis. Dietary fibre is rarely mentioned in recent research reports.
Nobody knows the answers to the obvious questions of what causes DD, what causes episodes of diverticulitis or who might get DD. The development of diverticulosis is closely associated with other Western diseases (12). A wind of change is blowing away the dietary fibre theory which has dominated DD for decades. Many researchers now accept that dietary fibre levels do not cause DD or prevent diverticulitis (13,14). Vegetarians can get DD and there are peoples in the world who eat very little fibrous food and do not get DD. However, diet does play a part in producing and relieving symptoms on an individual basis.
More recent research is directed at the changes in the colon wall nerves and muscles which precede the formation of diverticula and on the use of anti-inflammatory drugs. The types of bacteria inside the colon are being investigated along with the potential use of probiotics to prevent diverticulitis. A reputable probiotic food supplement might help, some of these also contain soluble fibre. The short and long term effects of food poisoning on the bowel, microbial food contaminants or changes in the water supply do not appear to have been assessed as triggers for diverticulitis. However, it makes sense to employ the best hygienic practices in food purchase, preparation and storage.
© 2012 Mary Griffiths PhD
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NOTE This article appeared in the Journal of the Bladder and Bowel Foundation. Feb. 2013