INTRODUCTION

Diverticular disease is a disease of civilisation. It is so common in westernised countries as to be almost normal in the elderly. Many people have diverticular disease without realising, because it causes no symptoms and does them no harm. In these individuals the disease may come to light by chance. Other people can have unpleasant symptoms. This leaflet will answer the questions for both groups of patients.

WHAT IS DIVERTICULAR DISEASE?

A diverticulum is the name given to a small pouch or pocket, which bulges out from any hollow structure in the body. The plural of diverticulum is diverticula (used when there are more than one pouch or pocket). The terms diverticulosis or diverticular disease usually refer to diverticula bulging out of the colon wall, usually in the sigmoid or left colon, but may involve the entire colon.

WHAT ARE THE DIFFERENCE BETWEEN DIVERTICULOSIS AND DIVERTICULTITIS?

Medical words ending ‘itis’ usually mean inflammation. The word diverticulitis describes the condition, which occurs when the diverticula become inflamed and painful. Diverticulosis (or diverticular disease) just means they are present.

HOW COMMON IS DIVERTICULAR DISEASE?

It is very common in western countries, especially with advancing age. About half the population in the UK who are over 70 years have diverticular disease. Only a small percentage have symptoms, and even fewer will ever require surgery. In Africa, it is less common possibly because of differences in diet.

WHAT CAUSES DIVERTICULAR DISEASE?

This question cannot be answered with certainty. However, it is thought that increased pressure within the bowel lumen probably forces the bowel lining through points of weakness in the muscle layers to form diverticula.

IS DIET IMPORTANT?

Comparisons between different countries show that diverticular disease is more common in those countries with a western diet - high in animal protein and low in vegetable or cereal fibre. A low intake of fibre results in smaller volume of stool passing through the colon, and in these situations the pressures produced inside the colon are higher. Thus, diverticular disease is thought to be one result of a low-fibre diet.

NOW I HAVE DIVERTICULAR DISEASE – WILL IT GO AWAY?

Once diverticula have formed they are permanent, but that does not mean to say that they necessarily cause trouble. Most patients with diverticular disease have no symptoms at all.

IS DIVERTICULAR DISEASE ASSOCIATED WITH CANCER?

There is no increased risk of cancer in diverticular disease. However, since diverticular disease and bowel cancer may cause similar symptoms, Mr Abulafi or a member of the team may want to be entirely sure that they have

excluded cancer by arranging a flexible sigmoidoscopy or colonoscopy (a telescopic inspection of the bowel). In some situations an x-ray of the colon (barium enema) may be requested.

WHAT ARE THE SYMPTOMS?

The major symptoms of diverticular disease are abdominal pain (usually in the lower left abdomen), cramps, distension alteration of bowel habit (either more constipated or more loose than usual) and occasionally, severe rectal bleeding. These symptoms occur in a small percentage of patients with the condition and are sometimes difficult to distinguish from Irritable Bowel Syndrome.

Diverticulitis - an infection of the diverticula - may cause one or more of the following symptoms: pain, chills, fever and change in bowel habits. More intense symptoms are associated with serious complications such as perforation, abscess or fistula formation (see below).

HOW IS DIVERTICULAR DISEASE TREATED?

Diverticulosis and diverticular disease are usually treated by diet and occasionally, medications to help control pain, cramps and changes in bowel habits. Increasing the amount of dietary fiber is often helpful and usually sufficient to relieve symptoms and return bowel activity to normal. A high-fibre diet includes:

• Wholemeal bread
• Brown rice
• Bran cereals
• Wholemeal pasta
• Plenty of fruit and vegetables

In addition, fibre intake can be supplemented by adding coarse bran to food (e.g. to yoghurt, soups, gravy, mashed potatoes, cereals, etc). In many situations, Mr Abulafi or a member of the team may prescribe dried fibre bulking agents:

• Ispaghula husk - Fybogel, Regulan, lsogel
• Sterculia - Normacol

In those few patients who still experience colicky pain and distension despite change in diet will need treatment with drugs called antispasmodics. These reduce the spasm in the colon which is often the cause of these symptoms.

Commonly used antispasmodics are:

• Mebeverine - Colofac
• Alvenne - Spasmonal
• Dicyclomine - Merbentyl
• Hyoscine - Buscopan
• Pipenzolate - Piptal
• Propantheline - Pro-Banthine
• Peppermint Oil - Colpermin, Mintec

WHAT ARE THE COMPLICATIONS OF DIVERTICULAR DISEASE?

There are four main complications:

• Diverticulitis: This means inflammation of the diverticular disease. It is probably due to bacterial infection, and usually treated by oral antibiotics. If the symptoms are severe, admission to hospital may be required for treatment with intravenous antibiotics and strict dietary restriction. Rarely, surgery is required but this is reserved for recurrent episodes, complications or severe attacks when there's little or no response to medication.
  
  In surgery, usually part of the colon - commonly the left or sigmoid colon - is removed and the colon is hooked up or "anastomosed" again to the rectum. Complete recovery can be expected. Normal bowel function usually resumes in about three weeks.
  
  
• Abscess formation
  
  Fistula to the bladder
  
  Perforation (bursting) of a diverticulum results in acute peritonitis or generalised inflammation of the whole abdominal cavity). This is serious and requires urgent surgery.
  
  
• Diverticulitis
  
  Abscess formation (a localised collection of pus close to the colon due to a local perforation). The abscess may have to be drained by a tube under ultrasound scan guidance or by surgery when the perforated piece of colon removed
  
  
• Formation of a fistula — perforation of a diverticulum into another structure, such as bladder or vagina, and forming a connection. Odd symptoms, such as passing air in the urine or a discharge from the vagina, may develop. Surgery is the only treatment.

Sometimes a colostomy is needed temporarily after an operation, but it is very rare to need one permanently

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