Diverticular disease of the colon: a conservative approach works best: the most effective treatment regimen is antibiotics, fluids, and bowel rest. When surgical intervention is indicated for diverticulitis, a single-stage elective procedure is the preferred method.(CME)(Disease/Disorder overview)(Cover story)

Publication: JAAPA-Journal of the American Academy of Physicians Assistants

Publication Date: 01-JUN-08

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Diverticular disease of the colon (DDC) used to be extremely rare, but the introduction of milled grains and refined sugars to the diet in industrialized countries has increased its prevalence. DDC continues to be rare in rural areas of Africa, Asia, and the Americas, where diets have remained relatively unchanged over time. Longitudinal studies have shown that persons from these areas who migrate to westernized societies develop DDC at a similar rate as those who are native to westernized cultures. (1)

Typically occuring in the fifth through seventh decades of life, DDC is often asymptomatic. When it has manifested itself, patients commonly present with left lower quadrant (LLQ) abdominal pain, fever, and leukocytosis. Changes in stool patterns, pneumaturia, fecaluria, and stool within the vagina are other potential signs. Initial treatment involves fluid resuscitation, antibiotics, and bowel rest. Complications or failure to respond to treatment usually indicates the need for surgical intervention. This article reviews the pathology, clinical manifestations, and current treatment options for DDC.

ETIOLOGY AND EPIDEMIOLOGY

Increased intraluminal pressures within the large intestine, specifically the descending and sigmoid colons, cause diverticula to form in the mucosal lining secondary to the increased propulsion needed to expel low-bulk stools (see Figure 1). Diverticula are outpouchings in the mucosal layers of the colon wall (see Figure 2, page 50). The outpouchings herniate through the colon musculature on the antimesenteric surface, into the pericolic fat of the mesocolon and/or the appendices epiploicae. A true diverticulum is an outpouching that penetrates through all layers of the colonic wall; these are rare and considered congenital. Outpouchings that penetrate only the mucosa and submucosa are more common. Diverticulitis occurs when the diverticula become-inflamed, most often because of an entrapped fecalith.

[FIGURE 1 OMITTED]

Up to 30 million middle-aged and elderly persons in the United States have diverticulosis, defined as the presence of left-sided diverticula without inflammation. Up to one-third of the US population will have diverticulosis by age 50 years, and two-thirds will have the condition by age 80 years. (2-6) Diverticulitis will develop in 10% to 25% of persons with diverticulosis. Approximately 10% of persons younger than 40 years will develop diverticulosis, with 2% to 7% of cases developing into diverticulitis. (5,7) Diverticulosis is more prevalent in men within this younger age group, whereas prevalence is essentially equal between the sexes among older patients. Between 5% and 25% of older patients will experience a complication, and up to 200,000 patients will require hospitalization. Approximately 50% of all patients hospitalized for diverticulitis eventually require surgery. (5,7)

Increased life expectancy is the most common factor to influence the prevalence of DDC. Total dietary fiber intake is consistently inversely related to prevalence of DDC. (8,9) Exercise has been inversely associated with the risk of DDC, but this has not been definitively proven. (7,10) Obesity was found to be a relative risk; however, alcohol and caffeine consumption and cigarette smoking do not increase the risk of DDC. (11) Consistent use of NSAIDs and acetaminophen increases the overall risk of symptomatic DDC, particularly those risks associated with bleeding. (12)

PATHOPHYSIOLOGY

Colonic peristalsis is the movement of contents through the colon via sequential, concentric contractions of circular (haustra coli) and longitudinal (taeniae coli) bands of musculature. Sequential contractions narrow the lumen of the bowel, increasing intraluminal pressure in that segment and propelling the stool toward evacuation. As a person ages, structural or inflammatory changes develop within the bowels, leading to progressive weakening of the musculature and connective tissues. The colonic musculature must exert significantly more...

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