Diverticular Disease: Diagnosis and Treatment - American Family Physician

D iverticular disease includes a spectrum of conditions sharing the underlying pathology of acquired diverticula of the colon. Because diverticular disease occurs almost exclusively in developed countries, it has been dubbed a “disease of Western Civilization.”1 acquired diverticula form through the relative weakness in the muscle wall of the colon at the site where arteries (the vasa recta) penetrate the muscularis layer to reach the mucosa and submucosa. Diverticula generally are multiple. each diverticulum is typically 5 to 10 mm in diameter, but at times they can exceed 20 mm. the most common site is the sigmoid colon, although diverticula can occur throughout the large bowel, with right-sided disease being more common in asians and in patients younger than 60 years.2,3 Vegetarians and others who consume large amounts of dietary fiber have a lower incidence of diverticula. although the pathogenic mechanisms of diverticular disease are poorly understood, they are clearly related to complex interactions of colon structure, intestinal motility, diet, and genetic features.4 the true prevalence of diverticula is unknown, but in one large observational study5 of 9,086 consecutive patients undergoing colonoscopy for all indications, the overall prevalence of diverticulosis was 27 percent and increased with patient age. Studies performed in the 1970s suggest that the prevalence of diverticula may be as high as 60 percent in patients older than 80 years, with no clear gender predilection. of patients with diverticula, 80 to 85 percent are believed to remain asymptomatic. three fourths of the remaining 15 to 20 percent of patients have symptomatic diverticular disease with colicky abdominal pain but no inflammation. the remaining one fourth (or approximately 5 percent of all patients with diverticula) develop diverticulitis, and a small number will develop complications of diverticulitis such as abscess formation, fistulas, obstruction, or hemorrhage.6 Table 1 compares the various diverticular syndromes. Diverticular disease refers to symptomatic and asymptomatic disease with an underlying pathology of colonic diverticula. Predisposing factors for the formation of diverticula include a low-fiber diet and physical inactivity. Approximately 85 percent of patients with diverticula are believed to remain asymptomatic. Symptomatic disease without inflammation is a diagnosis of exclusion requiring colonoscopy because imaging studies cannot discern the significance of diverticula. Fiber supplementation may prevent progression to symptomatic disease or improve symptoms in patients without inflammation. Computed tomography is recommended for diagnosis when inflammation is present. Antibiotic therapy aimed at anaerobes and gram-negative rods is first-line treatment for diverticulitis. Whether treatment is administered on an inpatient or outpatient basis is determined by the clinical status of the patient and his or her ability to tolerate oral intake. Surgical consultation is indicated for disease that does not respond to medical management or for repeated attacks that may be less likely to respond to medical therapy and have a higher mortality rate. Prompt surgical consultation also should be obtained when there is evidence of abscess formation, fistula formation, obstruction, or free perforation. (Am Fam Physician 2005;72:1229-34, 1241-2. Copyright © 2005 American Academy of Family Physicians.)