Diverticulitis

Introduction

Diverticulitis is a gastrointestinal condition characterized by the inflammation or infection of diverticula, which are small, bulging pouches that can form in the lining of the digestive system. These pouches are most commonly found in the lower part of the large intestine (colon). Diverticulitis can lead to severe abdominal pain, fever, nausea, and a marked change in bowel habits. This article delves into the pathophysiology, epidemiology, clinical presentation, diagnosis, management, and complications of diverticulitis.

Pathophysiology

Diverticula form when weak spots in the intestinal wall give way under pressure, causing pouches to protrude through the colon wall. The exact cause of diverticulitis is not well understood, but it is believed to involve a combination of factors such as increased intraluminal pressure, changes in the gut microbiota, and chronic low-grade inflammation. When these pouches become inflamed or infected, it results in diverticulitis.

The inflammatory process begins with micro-perforations in the diverticula, which can lead to localized inflammation and infection. In severe cases, this can progress to abscess formation, perforation, peritonitis, fistulas, or bowel obstruction.

Epidemiology

Diverticulitis predominantly affects older adults, with the incidence increasing significantly after the age of 40. It is more common in Western countries, possibly due to dietary factors such as low fiber intake. The prevalence of diverticulosis, the condition of having diverticula, is estimated to be around 50% in individuals over the age of 60, but only a small percentage of these individuals will develop diverticulitis.

Clinical Presentation

The clinical presentation of diverticulitis can vary from mild to severe. Common symptoms include:

Abdominal pain, typically in the lower left quadrant
Fever
Nausea and vomiting
Changes in bowel habits, such as constipation or diarrhea
Bloating and gas

In severe cases, patients may present with signs of peritonitis, such as a rigid abdomen, severe pain, and systemic symptoms like tachycardia and hypotension.

Diagnosis

The diagnosis of diverticulitis is primarily clinical, based on the patient's history and physical examination. However, imaging studies are often necessary to confirm the diagnosis and assess the extent of the disease. The most commonly used imaging modality is CT scan, which can reveal inflamed or infected diverticula, abscesses, and other complications.

Other diagnostic tools include:

Ultrasound: Useful in certain cases, especially in pregnant women or those who cannot undergo CT scans.
MRI: An alternative to CT, particularly in patients with contraindications to radiation.
Colonoscopy: Generally not recommended during the acute phase due to the risk of perforation but useful in the evaluation of chronic or recurrent diverticulitis.

Management

The management of diverticulitis depends on the severity of the disease. Treatment options include:

Conservative Management

Mild cases of diverticulitis can often be managed on an outpatient basis with:

Antibiotics: Commonly prescribed antibiotics include metronidazole combined with ciprofloxacin or trimethoprim-sulfamethoxazole.
Dietary modifications: A clear liquid diet is often recommended initially, gradually advancing to a low-fiber diet as symptoms improve.
Pain management: Analgesics such as acetaminophen are preferred. Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally avoided due to the risk of gastrointestinal bleeding.

Hospitalization

Patients with severe symptoms, significant comorbidities, or complications may require hospitalization for:

Intravenous antibiotics
Intravenous fluids
Pain control
Bowel rest

Surgical Intervention

Surgery is indicated in cases of:

Perforation with peritonitis
Large abscesses not amenable to percutaneous drainage
Fistulas
Recurrent episodes of diverticulitis

Surgical options include primary resection with anastomosis or Hartmann's procedure, depending on the patient's condition and the extent of the disease.

Complications

Complications of diverticulitis can be serious and include:

Abscess formation: Localized collections of pus that may require drainage.
Perforation: A hole in the bowel wall leading to peritonitis.
Fistulas: Abnormal connections between the colon and other organs, such as the bladder or vagina.
Bowel obstruction: Blockage of the intestinal lumen due to inflammation or scarring.
Strictures: Narrowing of the colon due to chronic inflammation and fibrosis.

Prognosis

The prognosis for patients with diverticulitis is generally good, especially with appropriate medical management. Most patients respond well to conservative treatment, and surgical intervention is successful in resolving complications. However, recurrent episodes of diverticulitis can occur, and some patients may require long-term dietary modifications and regular follow-up.

Prevention

Preventive measures for diverticulitis focus on lifestyle and dietary changes, including:

High-fiber diet: Increasing fiber intake through fruits, vegetables, and whole grains can help prevent the formation of diverticula.
Regular exercise: Physical activity promotes bowel regularity and reduces intraluminal pressure.
Adequate hydration: Drinking plenty of fluids helps maintain soft stools and reduces the risk of constipation.
Avoidance of smoking: Smoking cessation is recommended as smoking is associated with an increased risk of complications.