Clinical Notes : Gastroenterology
206. Diverticulosis and Diverticular Disease
The terms diverticulosis, diverticular disease, and acute diverticulitis are often used interchangeably but there is wide variation in clinical features (1)
The presence of diverticula without symptoms
The presence of diverticula with mild abdominal pain or tenderness and no systemic symptoms.
Sudden inflammation or infection associated with diverticula. Symptoms include constant abdominal pain, usually severe and localising in the left lower quadrant. Other features, including fever, may also be present.
Complicated acute diverticulitis
The presence of complications associated with inflamed or infected diverticula. These complications may include abscess, fistula, stricture perforation and sepsis.
Inflammation of the bowel related to Crohn's disease, ulcerative colitis, ischaemia or microscopic colitis. Symptoms may include abdominal pain and change in bowel habits with passage of blood.
Both genetic and environmental factors are causative, especially a low dietary fibre intake, which in Western populations is deemed as the predominant contributing factor.(2)
Other predisposing factors include (3), (4), (5), (6) :
decreased physical activity
increased red meat consumption
excessive alcohol and caffeine intake
steroids, and non-steroidal anti-inflammatory drugs
Other suggested aetiologies include
alterations in colonic wall structure (increased type III collagen synthesis, elastin deposition)
abnormal colonic motility, and colonic neurotransmitter dysfunction (decreased choline acetyltransferase, increased serotonin expression).(7), (8), (9)
Connective tissue abnormalities such as Ehlers-Danlos syndrome, or herniosis, have been implicated in the concurrence of disorders referred to as Saint's triad (hiatus hernia, colonic diverticulosis, gall stones).(10), (11)
Infection of the diverticula may be the cause of inflammation that results in diverticulitis.
There is no evidence to support the theoretical concern that ingested seeds and nuts could become trapped within a diverticulum and result in an episode of diverticulitis.
Clinical features of diverticulosis, diverticular disease, and acute diverticulitis
Investigations and referral - diverticulosis and diverticular disease (1)
Do not routinely refer people with suspected diverticular disease unless:
routine endoscopic and/or radiological investigations cannot be organised from primary care
colitis is suspected
the person meets the criteria for a suspected cancer pathway.
Management and advice - dicerticulosis (1)
The presence of diverticulosis can concern patients but reassurance should be given that most people will develop no symptoms.
No specific treatment is advised although lifestyle guidance is encouraged, which may reduce the risk of diverticular changes and/or the development of symptomatic disease in the future.
Lifestyle advice for people with diverticulosis and diverticular diasease
Management and advice - diverticular disease (1)
Do not offer antibiotics to people with diverticular disease.
Advise people to avoid non-steroidal anti-inflammatory drugs and opioid analgesia if possible, because they may increase the risk of diverticular perforation.
For advice on diet, fluid intake, stopping smoking, weight loss and exercise, follow the recommendations in section 1.1 on diverticulosis.
Advise people that:
the benefits of increasing dietary fibre may take several weeks to achieve
if tolerated, a high-fibre diet should be maintained for life.
Consider bulk-forming laxatives if:
a high-fibre diet is unacceptable to the person or it is not tolerated or
the person has persistent constipation or diarrhoea.
Consider simple analgesia, for example paracetamol, as needed if the person has ongoing abdominal pain.
Consider an antispasmodic if the person has abdominal cramping.
If the person has persistent symptoms or symptoms that do not respond to treatment, think about alternative causes and investigate and manage appropriately.
Diverticular diasease - antimicrobial prescribing
Choice of antibiotic for adults aged 18 years and over
with suspected or confirmed acute diverticulitis
1. Diverticular disease : diagnosis and management
NICE guideline NG147
Published 27 November 2019
2. Painter NS, Burkitt DP.
Diverticular disease of the colon: a deficiency disease of Western civilization.
Br Med J. 1971 May 22;2(5759):450-4
3. Andersen JC, Bundgaard L, Elbrønd H, et al.
Danish national guidelines for treatment of diverticular disease.
Dan Med J. 2012 May;59(5):C4453.
4. Wijarnpreecha K, Ahuja W, Chesdachai S, et al.
Obesity and the risk of colonic diverticulosis: a meta-analysis.
Dis Colon Rectum. 2018 Apr;61(4):476-83
5. Aune D, Sen A, Leitzmann MF, et al.
Body mass index and physical activity and the risk of diverticular disease: a systematic review and meta-analysis of prospective studies.
Eur J Nutr. 2017 Dec;56(8):2423-38
6. Aune D, Sen A, Leitzmann MF, et al.
Tobacco smoking and the risk of diverticular disease: a systematic review and meta-analysis of prospective studies.
Colorectal Dis.2017 Jul;19(7):621-33
7. Lin OS, Soon MS, Wu SS, et al.
Dietary habits and right-sided colonic diverticulosis.
Dis Colon Rectum. 2000 Oct;43(10):1412-8.
8. Bode MK, Karttunen TJ, Makela J, et al.
Type I and III collagens in human colon cancer and diverticulosis.
Scand J Gastroenterol. 2000 Jul;35(7):747-52.
9. Bassotti G, Battaglia E, Spinozzi E, et al.
Twenty-four hour recordings of colonic motility in patients with diverticular disease: evidence for abnormal motility and propulasive activity.
Dis Colon Rectum. 2001 Dec;44(12):1814-20
10. Leganger J, Søborg MK, Mortensen LQ, et al.
Association between diverticular disease and Ehlers-Danlos syndrome: a 13-year nationwide population-based cohort study.
Int J Colorectal Dis. 2016 Dec;31(12):1863-7
11. Hauer-Jensen M, Bursac Z, Read RC.
Is herniosis the single etiology of Saint's triad?
Hernia. 2009 Feb;13(1):29-34
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