Diverticula are small outpouchings that form along the walls of a hollow structure.

In the context of the large intestine, they're called colonic diverticula, but they can form in the small
intestine, as well as other spots like along the esophagus.

Diverticula usually form at weak spots along the wall, like where a blood vessel penetrates the
muscle layer of the intestine.

Now there are two types of diverticula. The first is a true diverticula which is a herniation that
involves all layers of the intestinal wall - like a Meckel’s diverticulum.

The second is a false or pseudodiverticula which is where only the mucosa and submucosa slide
through the intestinal wall, and these end up being more common.

Risk factors for diverticula, including eating a high-fat, red meat diet that’s low in fiber.

Diverticulosis is the presence of diverticula and when there’s colonic diverticula, typically these

happen in the left and sigmoid colon- the rectum is usually spared.

Sometimes it’s asymptomatic, and diverticulosis is diagnosed incidentally during an abdominal scan

or a colonoscopy that was needed for another reason.

When diverticulosis is symptomatic, it’s called diverticular disease.

Typically diverticular disease causes some abdominal pain and a CT-scan usually shows

some bowel thickening. But at this stage, treatment is mainly encouraging a high-fiber diet
with grains and vegetables.

But at any point diverticulosis can cause complications.

One complication is bleeding due to weakening and breaking of blood vessels near a diverticula.

Mild bleeding can cause painless hematochezia, but severe bleeding can lead to hypovolemic shock.

When there’s bleeding, depending on the severity, lab work and resuscitation are usually done.

Labs include a CBC to look for signs of anemia and assess the platelet count.

If there are signs of hypovolemia, intravenous fluids are given.

To see if the bleeding is coming from the upper GI tract, gastric lavage- which is where fluids are
placed in the stomach and then suctioned back out to look for signs of bleeding - and an upper
endoscopy can be done as well.

After that, a colonoscopy is performed within 24 hours of presentation to identify and stop the
source of the bleeding using endoscopic therapy.

One option is to inject the site of bleeding with epinephrine.

Alternatively, the vessel can be treated with thermocoagulation using cautery probes.

Cautery probes use an electrical current to melt a tiny blood vessel and seal it shut to stop the
bleeding.

If the source of bleeding isn’t identified using colonoscopy or if the bleeding can’t be

stopped endoscopically, then angiography can be used. That’s where a contrast agent is injected into
a blood vessel and then imaging is done to identify the location of any active bleeding. Unfortunately,
it may miss intermittent bleeds.

Now, if a source of active bleeding is found through angiography, then vasoconstricting medication

like vasopressin can be given, or the bleeding vessel can be embolized.

In embolization, the bleeding vessel is mechanically blocked using coils or polyvinyl alcohol particles

that are delivered through a catheter.

If neither colonoscopy nor angiography are able to identify and stop the bleeding, then surgery is

required and often a segmental colectomy is done. That’s where part of the colon is removed.

Another complication of diverticulosis is acute diverticulitis - which is an infection of the diverticula.

Typically it starts when there’s increased pressure in the lumen of the intestines or food impaction in
the diverticulum that leads to micro-perforations in the diverticula.

The bacteria in the lumen of the gut dive into these microperforations, and cause infection within the
wall of the diverticula.

Symptoms include left lower quadrant abdominal pain and fever, along with a change
in bowel habits, like alternating constipation and diarrhea.

Acute diverticulitis can also lead to the formation of an abscess within the inflamed diverticula.

The symptoms of a diverticular abscess are about the same as the symptoms of acute diverticulitis,

but usually with an abscess, the oral antibiotics used for acute diverticulitis don’t work as well, and
the fever and other symptoms persist.

If the inflamed diverticula is near another organ or skin surface it can also create a fistula, and this
most commonly occurs with the bladder. When that happens it’s called a colovesical fistula.

In a colovesical fistula there can be dysuria, pneumaturia -which is the passage of gas in the urine, as
well as fecaluria- which is the passing of stool in the urine. Yep, it’s pretty hard to forget that set of
symptoms!

Acute diverticulitis can also lead to a partial obstruction of the colon due to the inflammation, and

that can cause abdominal pain, distention, and vomiting.

Finally, an inflamed diverticula can perforate and cause peritonitis. Clinically that can result in a

tender, distended abdomen with guarding and rigidity.

The lab work for acute diverticulitis and its complications include a CBC, looking for leukocytosis,
along with electrolytes- especially if there’s dehydration due to diarrhea- and urine analysis, which
can show sterile pyuria due to inflammation near the bladder.
If there’s acute abdominal pain, then an AST and ALT, alkaline phosphatase, bilirubin, amylase,
and lipase can help rule out other potential causes like acute pancreatitis or cholecystitis.

If the individual has ongoing diarrhea, then stool cultures

for Salmonella, Shigella, Yersinia, Campylobacter, and E.coli can be sent.

In addition, stool microscopy to search for ova and parasites along with testing for C.difficile toxin are

done if those are suspected.

Acute diverticulitis is usually diagnosed with a CT scan with contrast of the abdomen and pelvis,

which will show colonic diverticula, with localized bowel wall thickening, and increased density in the
surrounding fat.

The CT can also identify the presence of an abscess or fistula.

If there’s an abscess, there will be a fluid collection surrounded by an inflamed diverticula.

A fistula will show the diverticula and local colonic thickening near a thickened bladder and may also

show air collections in viscera other than the bowel.

If there’s a partial bowel obstruction, then imaging shows dilated intestinal loops with air-fluid levels.

In individuals with perforation and peritonitis, the CT shows free air seen within the peritoneum.

A colonoscopy should not be performed in acute diverticulitis, because it increases the risk for

perforation and subsequent peritonitis.

Treatment of acute diverticulitis can differ based on the presence of complications.

If there’s uncomplicated acute diverticulitis, it can be treated with 7 to 10 days of oral antibiotics that
treat gram-negatives like Escherichia coli and anaerobes like Bacteroides fragilis.

Common regimens are Metronidazole plus either Ciprofloxacin or Levofloxacin or Trimethoprim-

Sulfamethoxazole.

In individuals that are allergic to Metronidazole, Moxifloxacin alone can be used instead.

If the individual is severely ill, then IV Metronidazole plus either IV Cefuroxime or IV Ciprofloxacin are

used instead, along with IV fluids and pain medications like Ketorolac.

If the CT scan shows an abscess bigger than 3 centimeters, then a percutaneous drainage of

the abscess is done as well.

After treating the abscess, the individual can have elective surgery to remove the diverticulum,
because there’s a high-risk for recurrent diverticulitis.

If there’s a fistula, then it has to be surgically closed.

If there’s obstruction, then the affected bowel may need to be surgically resected.

Finally, if there’s perforation and peritonitis, then surgery needs to be done right away for peritoneal
lavage and bowel resection.
Now, in some cases diverticular disease is associated with segmental colitis, which is inflammation of
the mucosa around the diverticula without involving the diverticular opening itself.

The cause is unclear, but it may be due to fecal stasis around the diverticula leading to irritation and
chronic inflammation.

Usually the symptoms are more chronic - like chronic diarrhea, intermittent crampy abdominal
pain in the left lower quadrant, and hematochezia.

Lab tests include a CBC that may show leukocytosis if the inflammation is severe.

If it’s severe, the fecal calprotectin- which is a protein released by neutrophils and a marker
for bowel inflammation- may be elevated.

A colonoscopy would show diverticular orifices with surrounding edema and erosions or aphthous

ulcers.

Treatment of segmental colitis is with oral Ciprofloxacin plus Metronidazole for 10 to 14 days -

slightly longer than uncomplicated acute diverticulitis.

In individuals that don’t respond to oral antibiotics, oral Mesalamine which is also called 5

aminosalicylic agent or 5ASA can be given for two weeks.

After that, the dose of these medications can be increased gradually until there’s a response.

In individuals that don’t respond to Mesalamine, oral Prednisone can be given for a week, and then
weaned off with a tapering dose over 6 weeks.

If an individual improves initially, but then relapses with symptoms after stopping the antibiotics,
then the same antibiotics are restarted but continued for a month.

Finally, if medical therapy fails, then surgical resection of the affected bowel may be needed.

Now, in rare cases, diverticula can occur in the small intestines, and they’re usually asymptomatic
and found incidentally on imaging that’s done for another reason.

Rarely, they can allow bacteria to overgrow, and that can cause malabsorption symptoms like
early satiety, bloating, upper abdominal discomfort, and steatorrhea.

The complications and treatment of small bowel diverticula are the same as colonic diverticula, but if
there’s malabsorption, then oral antibiotic therapy with Rifaximin or Norfloxacin can be tried.

Finally, there’s Meckel’s diverticulum, which is the most common congenital anomaly of

the gastrointestinal tract. It’s caused by incomplete obliteration of the vitelline duct and results in a
true diverticulum in the small bowel.

Like other small bowel diverticula, Meckel’s diverticulum is usually asymptomatic and discovered

incidentally.

In children, it can sometimes cause painless hematochezia or it can serve as a lead-point

for intussusception.
In intussusception, part of the intestine folds into the section next to it - like a telescope, and that
creates a lot of pressure which leads to bowel necrosis.

In adults, Meckel’s diverticulum can sometimes cause bowel obstruction as well as gastrointestinal

bleeding with no source found on an upper endoscopy or colonoscopy.

For individuals with painless hematochezia, an angiography may be done and this can show the
vitelline artery- which is a branch from the superior mesenteric artery.

Normally the vitelline artery shouldn’t be seen, but in this situation it’s there to supply
the Meckel’s diverticulum.

If Meckel’s diverticulum is suspected, then a Meckel’s scan can be done. That’s a nuclear study where
99 Technetium - a tracer that has an affinity for gastric mucosa - is given intravenously and then a
scintigraphy is performed to identify areas of ectopic gastric mucosa.

This is used to identify a Meckel’s diverticulum because Meckel’s contains some gastric

mucosa from fetal development.

In some cases, a Meckel’s diverticulum is only identified during surgical laparotomy of the abdomen.

Complications of Meckel’s diverticulum include small bowel obstruction due

to intussusception or volvulus.

In addition, there can be a Littre’s hernia, which is where the Meckel’s diverticulum pokes through an

opening in the abdominal wall, forming an abdominal wall hernia.

Usually, if Meckel’s diverticulum is found incidentally, then surgical resection is not necessary.

However, if the Meckel’s diverticulum is symptomatic, then an individual is initially stabilized with IV

fluids if they’re hypovolemic, or with nasogastric decompression if they’re obstructed.

And if there’s a gastrointestinal bleeding, then proton-pump inhibitors are used. After the initial
management, the Meckel’s diverticulum is surgically removed.

Summary

Alright, as a quick recap. If colonic diverticulosis causes symptoms it’s called diverticular disease, and

usually a high-fiber diet is recommended.

If there’s a complication like diverticular bleeding, then an upper endoscopy, colonoscopy,

and angiography can be used to identify and stop the bleeding.

If the bleeding can’t be stopped, then surgical resection of the affected bowel can be done.

Another complication is an infection, and that’s when it’s called acute diverticulitis.

Acute diverticulitis can lead to an abscess, a fistula, partial colonic obstruction and perforation

with peritonitis.
Lab work includes CBC, electrolytes and urine analysis, AST, ALT, bilirubin, amylase and lipase and
also stool cultures and microscopy if there’s diarrhea.

In addition, an abdominal and pelvic CT-scan is done.

Treatment of acute diverticulitis includes oral antibiotics, or if it’s severe, IV antibiotics, and

complications are mainly treated surgically.

Segmental colitis can sometimes be associated with diverticular disease and can cause chronic

diarrhea, abdominal pain, and intermittent hematochezia.

Lab work includes CBC and fecal calprotectin, and it’s confirmed with a colonoscopy.

Treatment includes antibiotics, and in severe cases, Mesalamine, Prednisone, and surgical resection

may be needed.

Small bowel diverticula can also form, and sometimes cause bacterial

overgrowth and malabsorption, in which case antibiotic therapy with Rifaximin or Norfloxacin may be
tried.

Meckel’s diverticulum is usually asymptomatic, but if present, symptoms include

painless hematochezia or signs of bowel obstruction.

Diagnosis is based on an angiography, a Meckel’s scan or abdominal exploration.

In symptomatic individuals, a surgical resection of the diverticulum can be done.

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