It is common to hear about gastroesophageal reflux, indigestion or irritable bowel syndrome, but it is also important to detail what other pathologies associated with the digestive system may appear and what to do to control them.
What is known as diverticular disease or diverticulitis?
Diverticular disease refers to any clinical condition that occurs as a consequence of having diverticula, which form in the weak points of the intestinal musculature of the colon.
The incidence of diverticulosis increases with age. It is frequent in industrialized countries. Its most frequent location is at the level of the sigma, which is the final part of the left colon before the rectum.
The appearance of diverticula is influenced by multiple factors, such as low fiber intake, altered intestinal motility, intestinal microbiota, altered collagen fibers that make up the intestinal wall, obesity and sedentary lifestyle, smoking, age and there is also a genetic predisposition.
What is the difference between diverticulosis and diverticulitis?
In diverticulosis, whether symptomatic or asymptomatic, there are no inflammatory phenomena.
In contrast, diverticulitis is the most frequent complication of diverticular disease and occurs when abrasion of the mucosa leads to inflammation of a diverticulum. Diverticulitis can be uncomplicated, when the inflammatory process affects only the diverticulum, or complicated, with the appearance of obstruction, fistula, abscess or perforation.
What are the symptoms of diverticulitis and diverticulosis?
Approximately 75-80% of patients with diverticula are asymptomatic.
In diverticulosis many patients present with non-specific symptoms, such as abdominal pain, in the area below the umbilicus to the pubic region and in the left hemiabdomen, flatulence or changes in bowel habit, preferably constipation. The pain usually increases with meals and improves after defecation. The picture of symptoms suffered by these patients is largely superimposable to that of patients with irritable bowel syndrome.
In diverticulitis the most common symptom is pain in the left iliac fossa, a region located in the left lower abdomen. Fever is frequent and only in the most severe cases signs of shock appear. Other symptoms that may appear are diarrhea, constipation and nausea. Urinary symptoms may occur. Other symptoms are those related to complications of diverticulitis, such as the appearance of an abdominal abscess, colovesical or colovaginal fistula or abdominal perforation.
Diagnosis of both pathologies: when is colonoscopy recommended and when is it not?
For many years the most commonly used imaging technique in the diagnosis of diverticulosis was the barium enema, which consists of introducing a barium contrast into the rectum and taking X-rays. This procedure provides information on the number of diverticula and their location. Many patients are diagnosed incidentally in the course of a radiological study for the diagnosis of abdominal symptoms unrelated to diverticulosis. However, the barium enema is an inaccurate test with a high false-negative and false-positive rate for the diagnosis of colonic polyps or neoplasms. Therefore, colonoscopy is currently recommended for all patients with symptomatic diverticulosis.
The diagnosis of acute diverticulitis is mainly based on clinical findings. Examination usually reveals the presence of pain on superficial and deep palpation with signs of peritoneal irritation. More than 50% of cases show leukocytosis on CBC. Plain abdominal radiography may show distended loops and hydro-aerial levels. Ultrasonography is a useful technique in the diagnosis of acute diverticulitis and may show signs of intestinal thickening or the presence of abscesses. Computed tomography (CT) is nowadays the imaging technique of choice for both acute diverticulitis and its complications. Colonoscopy is contraindicated in the case of suspected acute diverticulitis due to the risk of perforation, although once the inflammatory episode has subsided it is advisable to perform it to rule out other pathologies.
Treatment of diverticulitis and diverticulosis
Incidental diagnosis of diverticulosis does not require pharmacological treatment or clinical follow-up. The consumption of a diet rich in fruits and vegetables significantly reduces the risk of complications in patients with diverticular disease. Administration of antispasmodics, as in irritable bowel syndrome, may be helpful in relieving symptoms. Rifaximin (a non-absorbable antibiotic) has been proposed for uncomplicated symptomatic diverticulosis, as have probiotics and mesalazine, drugs that are even useful in preventing recurrence of symptomatic diverticulosis.
In uncomplicated diverticulitis it is sometimes possible to treat on an outpatient basis in those patients who present mild symptoms, tolerate oral intake and show no evidence of complicated diverticular disease. These patients can be treated with liquid diet and oral antibiotics. Treatment should be maintained for 7-10 days. In patients admitted with more intense inflammatory signs, bowel rest, serum therapy and intravenous antibiotic therapy should be given. When the initial symptoms improve, the consistency of the food ingested can be increased and it is usually recommended to increase the consumption of fiber, since some data suggest that this reduces the risk of recurrence of diverticulitis and prevents the appearance of new diverticula.
The association between fiber and rifaximin decreases the risk of developing an episode of diverticulitis. This antibiotic is therefore sometimes used for one week per month for 1 to 2 years. Classically, it has been postulated that after a second episode of acute uncomplicated diverticulitis, surgical treatment (excision of the affected colon, generally the sigma, open or laparoscopically) is recommended between 4 and 6 weeks after resolution of the inflammation, but this decision must be made on an individual basis by the Digestive System specialist, considering various factors such as age, associated comorbidities, severity and frequency of episodes of diverticulitis. Also the complications of diverticulitis: abscesses, fistulas, obstructions or perforations have their specific treatment.