Intestinal diverticula are outward protrusions in the intestinal wall in the area of the large intestine (colon). They represent a separate clinical picture. In diverticulitis, the diverticula are inflamed.
Diverticula usually occur in the left-sided section of the colon, particularly in the sigmoid colon. The sigmoid colon is located between the descending colon and the rectum. However, diverticula can also occur in other areas of the colon and throughout the rest of the gastrointestinal tract.
The presence of such diverticula in the colon is called diverticulosis, which, however, does not cause any symptoms. However, if the diverticula become noticeable through symptoms, they are referred to as diverticular disease.
Diverticula cannot regress.
In a false diverticulum(pseudoventricle), only the mucous membrane (mucosa) lining the intestine is pushed outwards. The overlying wall layer, the submucosa, may also be affected.
In contrast, a true diverticulum is a protrusion of the entire intestinal wall. The video shows what the clinical picture looks like in a colonoscopy:
Diverticula occur in many people and their frequency increases with age. In most cases, diverticula are asymptomatic.
It is only when the diverticula become inflamed, i.e. diverticulitis, that symptoms such as
- Severe abdominal pain, especially on the left side,
- indigestion (constipation, diarrhea, flatulence),
- painful indurations and
- fever.
The following dangerous complications can occur:
- Intestinal perforation: Tearing of the intestinal wall and leakage of air and feces into the abdominal cavity. This can cause the inflammation to spread to neighboring structures.
- Intestinal obstruction due to the thickening of the intestinal wall caused by the inflammation.
The symptoms often occur in episodes.
The presence of diverticula in the intestine and their pathological changes can be divided into different stages :
- Stage/type 0 (asymptomatic diverticulosis): Diverticula are present and do not cause any symptoms
- Stage/type 1 (acute uncomplicated diverticular disease/diverticulitis): Inflammation of the diverticula without complications, i.e. the intestinal wall is not perforated (torn)
- Stage/type 2 (acute complicated diverticular disease/diverticulitis): Inflammation of diverticula with complications. Either the intestinal wall is freely perforated or covered perforated (i.e. an abscess has formed)
- Stage/type 3 (chronic diverticular disease/diverticulitis): The disease is chronic and there are persistent or recurring symptoms. Complications such as fistulas (connecting ducts) or stenoses (constrictions) can also develop
- Stage/type 4: Bleeding of the diverticula
Illustration of diverticula in the colon © Henrie | AdobeStock
The exact causes for the development of diverticula are not known. In addition to age, certain stool characteristics may play a role in the development of diverticula. In particular, hard stools with a low-fiber diet and the resulting increased pressure in the bowel are considered a risk factor.
Stool stones and bacteria that collect in the protrusions can irritate the mucous membrane and cause inflammation. The inflammation can spread to neighboring structures such as the peritoneum and cause peritonitis. Fistulas and abscesses can also develop.
According to the specialist guideline on diverticular disease, risk factors that can be influenced for the development of diverticulitis are
- the consumption of red meat,
- smoking,
- obesity and
- certain underlying diseases, such as arterial hypertension.
In addition to
- medical history (patient questioning about symptoms, past illnesses and medication taken),
- a blood test for elevated inflammation levels (C-reactive protein = CRP, leukocytes) and
- physical examination (e.g. palpation of the abdomen and digital rectal examination)
imaging examinations are important for the diagnosis of diverticulitis. For example, the diverticula can be visualized using ultrasound examinations and computer tomography(CT).
A colonoscopy should only be performed during the non-inflammatory interval. Otherwise, there would be an increased risk of intestinal injury (perforation) in the case of diverticulitis. Colonoscopy is primarily used to
- clarify diverticular bleeding and, if possible, to stop it immediately and to rule out
- rule out malignant diseases.
Specialists in the treatment of diverticulitis are specialists in internal medicine and gastroenterology (gastrointestinal diseases) and visceral surgery experts for bowel operations.
GPs can treat most mild forms on an outpatient basis. Severe cases, on the other hand, must be treated as inpatients at special diverticulitis clinics, usually gastroenterology or visceral surgery clinics.
There are various treatment options depending on the severity or stage of the disease. Conservative measures such as dietary changes, antibiotic therapy and the administration of mesala are used for mild cases.
Surgery is required for stages of the disease,
- which do not respond to conservative measures or
- where complications such as an abscess or intestinal perforation have occurred or
- there is an increased risk of recurrence or complications.
Mild symptoms, such as irregular bowel movements, can often be successfully treated by regulating bowel movements.
Antibiotic therapy is not initially necessary for acute but uncomplicated diverticulitis. However, the prerequisite is that there is no increased risk of complications. However, close monitoring of the patient is necessary.
The risk of complications (perforation or abscess) is increased in patients with various pre-existing conditions, including
- arterial hypertension (high blood pressure),
- chronic kidney disease,
- under immunosuppression or
- an allergic disposition.
In this case, the doctor will prescribe antibiotic therapy . The intestines should be "spared" while taking antibiotics. A low-fiber diet is therefore recommended during treatment. Once the inflammation has healed, it should be switched back to a high-fiber diet.
Patients with acute complicated diverticular disease/diverticulitis should be treated as inpatients in hospital.
If there is no improvement with antibiotics, surgery should be performed. Abscesses can usually be drained by puncture or drainage.
Severe cases must be operated on immediately by an experienced abdominal surgeon (emergency operation). A severe course is present with intestinal perforation or peritonitis (inflammation of the peritoneum).
Even patients in this stage who have been successfully treated with antibiotics are advised to undergo surgery in the non-inflammatory phase.
Under certain circumstances, it may be advisable to surgically remove the diverticulum-bearing sections of bowel during the non-inflammatory interval. Removal is particularly advisable in the case of recurrent (recurrent) diverticulitis, but also in the case of frequent mild inflammation.
Stenoses are operated on if the narrowing leads to an obstruction of the passage of stool. Fistulas should also be treated surgically.
New studies show that the quality of life of patients with recurrent inflammation improves significantly more after surgery than regular antibiotics.
Most intestinal bleeding stops on its own. If this is not the case, it must be stopped. This can be done either
be performed.
Surgery can be performed during a colonoscopy © sakurra | AdobeStock
Surgical treatment of diverticulitis involves a sigmoid resection. This means that
- the diverticulum-bearing section of bowel (usually the sigmoid colon) and/or
- the rectosigmoid junction of the large intestine
is removed. If possible, this operation is performed as a minimally invasive procedure.
If there has already been a perforation and peritonitis, an open surgical procedure is often chosen for treatment.
The creation of an artificialanus praeter is not necessary in most cases today.
Diverticulitis can take very different courses. The inflammation of the diverticula often occurs in phases. This means that once the symptoms have subsided, the inflammation recurs. Depending on the severity, between two and 35 percent of patients who have had diverticulitis once are affected.
Most patients with diverticula remain asymptomatic. In some, however, intestinal perforation can occur during the first episode of the disease. Other patients, however, do not develop any complications, even with recurring episodes.
The risk of intestinal perforation is highest during the first relapse; the risk then decreases with each subsequent relapse. However, the risk of a further recurrence also increases with each relapse.
After a sigmoid resection , diverticula or diverticulitis can develop again in other sections of the bowel.
- Regular physical activity,
- adequate fluid intake,
- maintaining a normal weight and
- a high-fiber, vegetarian diet
are recommended to prevent diverticulitis.
