Elsevier

The Lancet

Volume 363, Issue 9409, 21 February 2004, Pages 631-639
The Lancet

Seminar
Diverticular disease of the colon

https://doi.org/10.1016/S0140-6736(04)15597-9Get rights and content

Summary

Colonic diverticulosis refers to small outpouchings from the colonic lumen due to mucosal herniation through the colonic wall at sites of vascular perforation. Abnormal colonic motility and inadequate intake of dietary fibre have been implicated in its pathogenesis. This acquired abnormality is typically found in developed countries, and its prevalence rises with age. Most patients affected will remain entirely asymptomatic; however, 10–20% of those affected can manifest clinical syndromes, mainly diverticulitis and diverticular haemorrhage. As our elderly population grows, we can anticipate a concomitant rise in the number of patients with diverticular disease. Here, we review the incidence, pathophysiology, clinical presentation, and management of diverticular disease of the colon and its complications.

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

Search strategy and selection criteria

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”,

References (119)

  • BrodribbAJ

    Treatment of symptomatic diverticular disease with a high-fibre diet

    Lancet

    (1977)
  • StollmanNH et al.

    Diagnosis and management of diverticular disease of the colon in adults: ad hoc practice parameters committee of the American College of Gastroenterology

    Am J Gastroenterol

    (1999)
  • KonvolinkaCW

    Acute diverticulitis under age forty

    Am J Surg

    (1994)
  • PerkinsJD et al.

    Acute diverticulitis: comparison of treatment in immunocompromised and nonimmunocompromised patients

    Am J Surg

    (1984)
  • McBeathRB et al.

    A 12-year experience with enterovesical fistulas

    Urology

    (1994)
  • KozarekRA

    Hydrostatic balloon dilation of gastrointestinal stenoses: a national survey

    Gastrointest Endosc

    (1986)
  • PotterGD et al.

    Lower gastrointestinal bleeding

    Gastroenterol Clin North Am

    (1988)
  • BoleySJ et al.

    Lower intestinal bleeding in the elderly

    Am J Surg

    (1979)
  • ZuckermanGR et al.

    Acute lower intestinal bleeding: part II—etiology, therapy, and outcomes

    Gastrointest Endosc

    (1999)
  • MeyersMA et al.

    Pathogenesis of bleeding colonic diverticulosis

    Gastroenterology

    (1976)
  • ZuccaroG

    Management of the adult patient with acute lower gastrointestinal bleeding

    Am J Gastroenterol

    (1998)
  • HunterJM et al.

    Limited value of technetium 99m-labeled red cell scintigraphy in localization of lower gastrointestinal bleeding

    Am J Surg

    (1990)
  • PainterNS et al.

    Diverticular disease of the colon: a deficiency disease of Western civilization

    BMJ

    (1971)
  • KyleJ et al.

    Incidence of diverticulitis

    Scand J Gastroenterol

    (1967)
  • LeeYS

    Diverticular disease of the large bowel in Singapore: an autopsy survey

    Dis Colon Rectum

    (1986)
  • WalkerAR et al.

    Epidemiology of noninfective intestinal diseases in various ethnic groups in South Africa

    Isr J Med Sci

    (1979)
  • OgunbiyiOA

    Diverticular disease of the colon in Ibadan, Nigeria

    Afr J Med Med Sci

    (1989)
  • MakelaJ et al.

    Prevalence of perforated sigmoid diverticulitis is increasing

    Dis Colon Rectum

    (2002)
  • RobertsPL et al.

    Current management of diverticulitis

    Adv Surg

    (1994)
  • SlackW

    The anatomy, pathology and some clinical features of diverticulitis of the colon

    Br J Surg

    (1962)
  • ChiaJG et al.

    Trends of diverticular disease of the large bowel in a newly developed country

    Dis Colon Rectum

    (1991)
  • LeviDM et al.

    Giant colonic diverticulum: an unusual manifestation of a common disease

    Am J Gastroenterol

    (1993)
  • HornerJ

    Natural history of the diverticulosis of the colon

    Am J Dig Dis

    (1958)
  • RyanP

    Changing concepts in diverticular disease

    Dis Colon Rectum

    (1983)
  • WhitewayJ et al.

    Elastosis in diverticular disease of the sigmoid colon

    Gut

    (1985)
  • BodeMK et al.

    Type I and III collagens in human colon cancer and diverticulosis

    Scand J Gastroenterol

    (2000)
  • StumpfM et al.

    Increased distribution of collagen type III and reduced expression of matrix metalloproteinase 1 in patients with diverticular disease

    Int J Colorectal Dis

    (2001)
  • WessL et al.

    Collagen alteration in an animal model of colonic diverticulosis

    Gut

    (1996)
  • WessL et al.

    Cross linking of collagen is increased in colonic diverticulosis

    Gut

    (1995)
  • SimpsonJ et al.

    Pathogenesis of colonic diverticula

    Br J Surg

    (2002)
  • ArfwidssonS et al.

    Pathogenesis of multiple diverticula of the sigmoid colon in diverticular diseases

    ActaChir Scan Suppl

    (1964)
  • PainterNS et al.

    Segmentation and the localization of intraluminal pressure in the human colon, with special reference to the pathogenesis of colonic diverticula

    Gastroenterology

    (1968)
  • PainterNS

    The aetiology of diverticulosis of the colon with special reference to the action of certain drugs on the behavior of the colon

    Ann R Coll Surg Engl

    (1964)
  • HodgsonJ

    Effect of methylcellulose on rectal and colonic pressures in treatment of diverticular disease

    BMJ

    (1972)
  • CortesiniC et al.

    Usefulness of colonic motility study in identifying patients at risk for complicated diverticular disease

    Dis Colon Rectum

    (1991)
  • SugiharaK et al.

    Motility study in right sided diverticular disease of the colon

    Gut

    (1983)
  • TomitaR et al.

    Role of nitric oxide in the left-sided colon of patients with diverticular disease

    Hepatogastroenterology

    (2000)
  • BurkittDP et al.

    Effect of dietary fibre on stools and the transit-times, and its role in the causation of disease

    Lancet

    (1972)
  • WolffW et al.

    Colonoscopy

    N Engl J Med

    (1973)
  • OrnsteinM

    Are fibre supplements really necessary in diverticular disease of the colon? A controlled clinical trial

    BMJ

    (1981)
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