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Diverticulosis

Last updated: September 28, 2021

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Diverticulosis is a type of diverticular disease that consists of the formation of abnormal outpouchings of the colonic mucosa (diverticula). These can develop due to a combination of chronically elevated intraluminal pressures due to chronic constipation (e.g., due to low-fiber diets, lack of physical exercise) and age-related weakening of connective tissue. This typically causes the colonic mucosa to herniate through areas of weakness in the muscular layer. The sigmoid colon is most commonly involved. Incidence increases with age, and approx. 50% of individuals are affected by the 7th decade of life. Diverticulosis is typically asymptomatic but occasionally presents with altered bowel habits and/or abdominal discomfort. It is often an incidental finding during the diagnostic evaluation of abdominal pain and other gastrointestinal conditions. Colonoscopy is the diagnostic modality of choice for symptomatic diverticulosis but is contraindicated if acute inflammation of the diverticula (i.e., diverticulitis) is suspected. Management is typically aimed at preventing disease progression and treating complications, e.g., diverticulitis, painless diverticular bleeding (an important cause of severe lower GI bleeding), and diverticular disease-associated colitis (chronic inflammation of diverticula and surrounding colonic mucosa).

See also “Diverticulitis.”

  • Diverticula: blind pouches that protrude from the gastrointestinal wall and communicate with the lumen
    • True diverticulum; : a type of diverticulum that affects all layers of the intestinal wall.
    • False diverticulum or pseudodiverticulum: type of diverticulum that involves only the mucosa and submucosa and does not contain muscular layer or adventitia.
      • Most common type of gastrointestinal diverticula
      • Typically acquired
  • Diverticulosis: the presence of multiple colonic diverticula without evidence of infection [1]

  • In the US, ∼ 50% of individuals > 60 years have diverticulosis [2]
  • More common in high-income countries due to the higher prevalence of a high-fat, low-fiber diet

Epidemiological data refers to the US, unless otherwise specified.

References:[4][5]

The formation of diverticula is considered multifactorial.

  • Increased intraluminal pressure, e.g., due to chronic constipation
  • Weakness of the intestinal wall
    • Age-related loss of elasticity of the connective tissue
    • Physiological gaps in the intestinal wall, which occur where blood vessels penetrate, predispose to protrusion and herniation of intestinal mucosa and submucosa.
  • Localized particularly in the sigmoid colon

Asymptomatic diverticulosis [8]

  • Typically an incidental diagnosis
  • No workup required

Symptomatic diverticulosis [9][10][11][12][13]

Colonoscopy is the diagnostic modality of choice for symptomatic diverticulosis.

  • Asymptomatic diverticulosis
    • No treatment can reverse the growth of existing diverticula.
    • The goal is the prevention of progression (see “Prevention”).
  • Symptomatic uncomplicated diverticular disease: unclear [6][12]
  • Complicated diverticular disease (e.g., diverticulitis): See “Complications.”

Consider the following measures to prevent disease progression and development of complications. See “Management of diverticulitis” for secondary prevention of recurrent diverticulitis. [14][[15]

  • Dietary modification, e.g., high-fiber diet, DASH diet, or vegetarian diet [16]
  • Weight reduction
  • Vigorous physical activity
  • Smoking cessation
  • Treatment of alcoholism

We list the most important complications. The selection is not exhaustive.

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  2. Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021; 160 (3): p.906-911.e1. doi: 10.1053/j.gastro.2020.09.059 . | Open in Read by QxMD
  3. AlFraih Y, Robinson T, Stein N, Kam A, Flageole H. Quality Assurance and Performance Improvement Project for Suspected Appendicitis. Pediatric Quality & Safety. 2020; 5 (3): p.e290. doi: 10.1097/pq9.0000000000000290 . | Open in Read by QxMD
  4. Strate LL, Morris AM. Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology. 2019; 156 (5): p.1282-1298.e1. doi: 10.1053/j.gastro.2018.12.033 . | Open in Read by QxMD
  5. Adam V Weizman and Geoffrey C Nguyen. Diverticular disease: Epidemiology and management. Canadian Journal of Gastroenterology and Hepatology. 2011 .
  6. Goldblum JR, Lamps LW, McKenney J, Myers JL. Rosai and Ackerman's Surgical Pathology - 2 Volume Set. Mosby ; 2017
  7. Weizman AV, Nguyen GC. Diverticular disease: Epidemiology and management. undefined. 2011 .
  8. Reichert MC, Lammert F. The genetic epidemiology of diverticulosis and diverticular disease: Emerging evidence. undefined. 2015 .
  9. Tursi A, Elisei W, Franceschi M, Picchio M, Di Mario F, Brandimarte G. The prevalence of symptomatic uncomplicated diverticular disease could be lower than expected. Eur J Gastroenterol Hepatol. 2021; Publish Ahead of Print . doi: 10.1097/meg.0000000000002142 . | Open in Read by QxMD
  10. Wilkins T, Baird C, Pearson AN, Schade RR. Diverticular bleeding.. Am Fam Physician. 2009; 80 (9): p.977-83.
  11. Floch MH. Netter's Gastroenterology. Elsevier Health Sciences ; 2019
  12. Snyder MJ. Imaging of Colonic Diverticular Disease. Clinics in Colon and Rectal Surgery. 2004; 17 (3): p.155-162. doi: 10.1055/s-2004-832696 . | Open in Read by QxMD
  13. ACR - Practice parameter for the performance of fluoroscopic contrast enema examination in adults.
  14. American College of Radiology (ACR) Appropriateness Criteria® - Left Lower Quadrant Pain. https://acsearch.acr.org/docs/69356/Narrative/. Updated: January 1, 2018. Accessed: August 28, 2019.
  15. Feuerstein JD, Falchuk KR. Diverticulosis and Diverticulitis. Mayo Clinic Proceedings. 2016; 91 (8): p.1094-1104. doi: 10.1016/j.mayocp.2016.03.012 . | Open in Read by QxMD
  16. Salzman H, Lillie D. Diverticular disease: diagnosis and treatment.. Am Fam Physician. 2005; 72 (7): p.1229-34.
  17. Onur MR, Akpinar E, Karaosmanoglu AD, Isayev C, Karcaaltincaba M. Diverticulitis: a comprehensive review with usual and unusual complications. Insights into Imaging. 2016; 8 (1): p.19-27. doi: 10.1007/s13244-016-0532-3 . | Open in Read by QxMD
  18. Pemberton JH. Colonic diverticular bleeding. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/colonic-diverticular-bleeding.Last updated: April 8, 2015. Accessed: December 13, 2016.
  19. Haddad FG, El Bitar S, Al Moussawi H, Chang Q, Deeb L. Diverticular Disease-associated Colitis: What Do We Know? A Review of Literature.. Cureus. 2018; 10 (2): p.e2224. doi: 10.7759/cureus.2224 . | Open in Read by QxMD
  20. Shahedi K. Diverticulitis. In: BS Anand, Diverticulitis. New York, NY: WebMD. http://emedicine.medscape.com/article/173388. Updated: June 17, 2016. Accessed: December 12, 2016.
  21. Pemberton JH. Acute colonic diverticulitis: Medical management. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/acute-colonic-diverticulitis-medical-management.Last updated: October 24, 2016. Accessed: December 13, 2016.
  22. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50 (2): p.133-164. doi: 10.1086/649554 . | Open in Read by QxMD
  23. Cuomo R, Cargiolli M, Cassarano S, Carabotti M, Annibale B. Treatment of diverticular disease, targeting symptoms or underlying mechanisms. Curr Opin Pharmacol. 2018; 43 : p.124-131. doi: 10.1016/j.coph.2018.09.006 . | Open in Read by QxMD
  24. Wilkins T, Embry K, George R. Diagnosis and management of acute diverticulitis.. Am Fam Physician. 2013; 87 (9): p.612-20.
  25. Tursi A, Elisei W. Role of Inflammation in the Pathogenesis of Diverticular Disease. Mediators Inflamm. 2019; 2019 : p.1-7. doi: 10.1155/2019/8328490 . | Open in Read by QxMD