Sources of information included: authors' published work and research; and original research, reviews, and practice guidelines identified by computer database search—eg, MEDLINE, LexisNexis, The Cochrane Library, and Science Citation Index. Most recent publications were prioritised. Search terms included: “diverticulosis”, “diverticulitis”, “diverticular disease”, “diverticular hemorrhage”, “gastrointestinal bleeding”, “diverticular abscess”, “diverticular fistula”, “colonoscopy”, “endoscopy”,
SeminarDiverticular disease of the colon
Section snippets
Epidemiology
Prevalence of colonic diverticulosis is difficult to measure because most patients are asymptomatic. In early (1920–1940) autopsy and barium enema series, rates of 2–10% were reported.1 Data show a substantial rise in colonic diverticula within the past few decades. Prevalence of diverticular disease increases with age, from less than 10% in people younger than age 40 years to 50–66% in patients older than age 80 years.1, 2, 3 No sex differences seem to exist.
Diverticulosis has been labelled a
Pathological anatomy
Colonic diverticula typically form in parallel rows between the taeniae coli because of weakness of the muscle wall at sites of penetration of the vasa recta supplying the mucosa. In European and US populations, diverticula arise mainly in the distal colon, with 90% of patients having sigmoid colon involvement and only 15% having right-sided diverticula.3, 9, 10, 11 This finding is in contrast to that seen in Asian populations, in which right-sided involvement is more prominent.5, 12
Diverticula
Colonic wall resistance
Early gross descriptions of diverticular colons typically noted thickening of muscle wall and shortening of the taeniae coli, with resultant concertina-like bunching of haustral folds. Although muscle contraction is noted, routine histology has not generally indicated muscle hypertrophy. Findings of electron microscopic studies have shown that diverticular colonic walls consist of structurally normal muscle cells but elastin deposition is amplified by more than 200% in muscle cells in the
Uncomplicated diverticulosis
Most patients, perhaps 75–80%, with anatomical diverticulosis will remain asymptomatic throughout their lifetime. Of the few who develop complications, diverticulitis—and its difficulties such as abscesses, fistulas, or obstruction—is the most usual manifestation, followed by diverticular haemorrhage, both of which are addressed below.
Diverticulitis
Diverticulitis is the most usual clinical complication of diverticular disease, affecting 10–25% of patients with diverticula.3 The process by which diverticulitis arises has been likened to that of appendicitis, with a diverticulum becoming obstructed by inspissated stool in its neck.40 This faecalith abrades the mucosa of the sac, causing inflammation and expansion of usual bacterial flora, with diminished venous outflow and localised ischaemia. Bacteria may breach the mucosa and extend the
Haemorrhage
Important lower gastrointestinal bleeding can be caused by diverticula, vascular ectasias, colitis, or neoplasms.10, 83, 84, 85 Diverticular sources have been reported to be the most typically identified cause, accounting for greater than 40% of lower gastrointestinal bleeding episodes.86, 87 Severe haemorrhage can arise in 3–5% of patients with diverticulosis.10, 88, 89 Despite the fact that most diverticula are in the left colon in western individuals, the site of bleeding may more often be
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