Diverticular disease

Disease Description (Causes and Symptoms)

• Definition summary: Diverticular disease is a condition in which weakened walls of the esophagus, stomach, small intestine, or colon bulge outward to form pouches (diverticula), occurring most often in the colon. False (pseudodiverticula) are forms in which only the mucosa and submucosa herniate (usually acquired and common in the left colon), while true diverticula include the entire intestinal wall (congenital and common in the right colon).
• Causes and pathophysiology: Major causes include reduced elasticity of the colon wall with aging, weakening at sites where local blood vessels pass through, increased pressure inside the colon due to constipation, and insufficient dietary fiber. Bleeding may occur if repeated inflammation damages blood vessels.
• Epidemiology and characteristics: In Western countries, left-sided diverticula (especially in the sigmoid colon) are common, while right-sided diverticula are relatively more common in East Asia. Prevalence increases with age (approximately 50% in people aged 65 and older), and approximately 65% has been reported in people aged 85 and older.
• Main symptoms
  • Asymptomatic (diverticulosis): Often discovered incidentally.
  • Diverticulitis (inflammation/infection): Localized abdominal pain (mainly in the left lower abdomen or on the right side), fever, chills, changes in bowel habits, and a feeling of abdominal bloating.
  • Bleeding: Appears as rectal or anal bleeding and may be an emergency in cases of massive bleeding. Bleeding is more common in the right colon.
  • In cases of complications: Abscess, perforation, peritonitis, fistula, and intestinal obstruction may occur.

Treatment Methods

• General principles: Treatment is divided into conservative (medical) treatment and surgical treatment depending on symptoms and the presence or absence of complications.
• Conservative (nonsurgical) treatment
  • Asymptomatic diverticulosis: A high-fiber diet (increased dietary fiber), adequate hydration, regular exercise, and improved bowel habits can reduce the risk of recurrence and complications.
  • Uncomplicated (mild) diverticulitis: Recent studies suggest considering selective use of antibiotics, but traditionally oral antibiotics have been used (e.g., ampicillin-based non-targeted antibiotic combinations or a fluoroquinolone plus metronidazole). If outpatient treatment is possible, rest, oral hydration, and oral medications are used.
  • In severe cases or when hospitalization is required: Fasting, parenteral nutrition and IV fluids, IV antibiotics (covering mixed gram-negative bacteria and anaerobes), and pain control. Abdominal CT is used to evaluate complications such as abscesses.
  • Abscess: Percutaneous drainage may be performed if the abscess is large or symptomatic.
  • Bleeding: Endoscopic treatment, angiography (embolization), and, if necessary, surgery may be considered to achieve hemostasis.
• Surgical treatment
  • Indications: Peritonitis caused by perforation, uncontrolled massive bleeding, repeated or recurrent severe diverticulitis (or recurrent disease accompanied by complications), abscess, fistula, intestinal obstruction, and so on.
  • Common surgical methods: Resection of the affected area (e.g., sigmoid colectomy), usually with primary anastomosis (a temporary ostomy may be necessary depending on the situation). In patients with severe contamination or instability, a Hartmann procedure (resection followed by ostomy) may be performed.
  • Timing of surgery: Emergency surgery is performed in acute severe cases, while elective resection may be considered in cases of repeated recurrence. Whether to perform surgery is determined comprehensively based on the patient's condition, recurrence frequency, and risk of complications.
• Precautions regarding medications and lifestyle management
  • NSAIDs, steroids, and anticoagulants may increase the risk of diverticular bleeding and inflammation, so consult the attending physician if you are taking them.
  • The former recommendation to avoid seeds and nuts is based on insufficient evidence, and blanket restrictions are increasingly no longer recommended.
  • Smoking cessation, weight control, and regular exercise can help with prevention.

Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items to bring (recommended)
  • A list of currently used medications, including prescriptions, OTC medications, anticoagulants, and aspirin
  • Copies of previous medical certificates, surgical records, abdominal CT scans, colonoscopy results, and blood test results, if possible
  • A symptom diary: location, severity, and duration of pain; observed fever; and blood in the stool (amount and color)
  • Information about allergies (medications, contrast agents, etc.) and underlying conditions (cardiovascular disease, diabetes, etc.)
• Key information to show the doctor during the outpatient visit
  • Whether you have recently had fever, chills, vomiting, changes in bowel movements, or bleeding during bowel movements
  • The exact location of the pain and factors that worsen it
  • Recent CT or endoscopy results, if available
• Example questions (for the patient to check personally)
  • If the pain worsens, when should I go to the emergency room, and what symptoms should I look for?
  • Could any of the medications I am currently taking worsen the diverticular problem?

General Example Questions to Ask the Doctor

• What tests or imaging studies (CT, colonoscopy, etc.) are immediately needed for this condition?
• What are the effects and side effects of the antibiotic you are prescribing now?
• What specific lifestyle changes should I make to reduce the risk of recurrence?
• When can I resume a normal diet and regular activities?
• If surgery is considered necessary, what type of surgery do you recommend? How high is the risk of complications?

Examples of Condition-Specific Questions

• Based on the findings of my CT (or colonoscopy), how do you determine whether to recommend surgery or whether conservative treatment is sufficient?
• I have had recurrent diverticulitis. Are there any specific dietary, medication, or preventive measures you particularly recommend to reduce the recurrence rate?

(Note: Diagnosis and treatment vary depending on the individual's condition. The information above is general guidance. If symptoms occur, consult your attending physician, or visit a medical institution immediately in an emergency.)