Diverticulitis: Risk Factors (ex. Low Fiber Diets), Symptoms, Diagnosis, Treatment and Complications

hey everyone in the system are talking

about the condition known as

diverticulitis in this us we're in talk

about what this condition is risk

factors signs and symptoms of this

condition we also can talk about how we

diagnose and treat it and what are some

of the complications of diverticulitis

so to begin we're gonna break down the

word diverticulitis diverticulitis

diverticula and itís simply means the

condition due to inflammation of a

diverticula the prefix diverticula

stands for diverticula and the suffix

itis means inflammation and this differs

from the word diverticulosis you might

have heard of this condition

diverticulosis means an abnormal

condition of having diverticula so these

are not the same condition if a person

has diverticula they have diverticulosis

if those diverticula become inflamed

they have diverticulitis so what are

diverticula and what is diverticulitis

more specifically so diverticula are

sacklike outpouching x' of the large

intestine so you can see right here in

this image here's a large intestine and

here are these little outpouching these

little bulges in the large intestine

these are diverticula so having these

simply means you have diverticulosis if

these become inflamed for whatever

reason then you have diverticulitis so

the presence of diverticula again is

known as the condition of diverticulosis

and diverticulitis is inflammation of a

diverticulum due to a micro perforation

generally speaking oftentimes what

happens is there is a fecal if or a

small piece of feces that essentially

blocks or gets lodged in one of the

diverticula causing inflammation so that

is generally what caused diverticulitis

diverticulitis is one of several

diverticular diseases so there are

several by particular diseases

diverticulitis is just one of them

so others include symptomatic

uncomplicated died particular disease

can present similarly to diverticulitis

but it often is only transient it

doesn't last very long so they can have

some lower abdominal pain that only

occurs briefly and doesn't have other

associated issues and there's also a

condition known as diverticular

hemorrhage where there are little

vessels that are associated with a

diverticulum that can actually break and

cause bleeding and people can see

hematochezia or blood in their stool now

the etiology of diverticulitis is due to


development of diverticula as we

mentioned before in the large intestine

and the development of these diverticula

is due to increase colonic pressure and

decreased bowel compliance we're going

to talk about more about this in the

next slide in ten to twenty five percent

of patients with diverticulosis will

develop diverticulitis so what are some

of the risk factors of diverticulitis

some of the risk factors include

increasing age this may actually be the

most important risk factor you can

imagine that as we age bowel compliance

can decrease and other risk factors can

accumulate over time so generally

speaking 60 years and older is when

you're gonna see diverticulitis it's

very uncommon in individuals less than

40 years of age and again as we

mentioned before as we age our bowels

become less compliant the second risk

factor is decreased fiber intake this is

also a very important risk factor with

individuals that have a very low fiber

diet they generally have increased

constipation and over the course of an

individual's life if they've had

decreased fiber intake they can have

chronic constipation chronic

constipation can lead to increased

colonic pressure and the increased

colonic pressure can lead to a less

compliant bowel with essentially these

diverticula popping out in areas of

weakness in the battle wall so again

over time the bowel wall becomes weaker

just because of that increased colonic

pressure and eventually an area in the

bowel wall can blow out forming a

diverticula another risk factor is a

high red meat intake along with high-fat

diet intake another risk factor is lack

of vigorous physical activity smoking

can also be a risk factor for

diverticulosis in diverticulitis another

risk factor is high body mass index and

another one is non-steroidal

anti-inflammatory or NSAIDs

use and generally this is a chronic use

so all of these risk factors can

increase the risk for developing

diverticulosis and diverticulitis so if

we can manage these risk factors we can

decrease the risk of having recurrent

diverticulitis now you might have heard

of the idea that eating nuts corn and

seeds can worsen diverticular diseases

but I just want to point out that

there's not a very significant evidence

to show that generally speaking nuts

corn and seeds do not appear to be

associated with an increased risk of

diverticulosis diverticulitis or

particular bleeding so I wanted to

mention that here now before we move on

I want to talk about some definitions

with regards to diverticulitis so a true

diverticula is a outpouching

of all three layers of the colon mucosa

submucosa and muscular layer whereas a

pseudo diverticular or a false

diverticula only has the two layers

mucosa and submucosa that out pouches

through the muscle there's also what we

call simple or uncomplicated

diverticulitis this is an acute

diverticulitis without an Associated

complication I'm gonna mention what

these complications are in a moment and

a complicated diverticulitis is

essentially acute diverticulitis with a


so these complications can be bowel

obstruction perforation fistula and/or

abscess so we're gonna talk about more

about these complications a little later

as well so what are some of the signs

and symptoms of diverticulitis one of

the cardinal symptoms of diverticulitis

is abdominal pain in it is a constant

pain that generally occurs in the left

lower quadrant this is the most common

location of abdominal pain especially in

Western countries with Western diets so

again here's the left side of the

patient if we're looking straight on a

patient here's the left side right in

the left lower quadrant is where the

majority of individuals are gonna have

pain this is different in other

populations right lower quadrant pain so

pain in this area or super pubic pain in

this area can occur in Asian populations

so you can see this in Asia where

diverticulitis can be more associated

with right lower quadrant pain or

suprapubic pain with regards to the

right lower quadrant pain or the super

pubic pain you want to suspect

reticulatus when the pain is lasting

longer than three days because generally

we think about diverticulitis when we

had two pain in the left lower quadrant

the pain can be diffused so it might not

be necessarily localized to one area or

the other could be diffusely through the

entire abdomen there is also associated

gastrointestinal symptoms as well so

we've got the abdominal pain but there's

also other associated symptoms some of

these can include nausea and vomiting

when you see knowledge and vomiting with

diverticulitis you want to worry about

obstruction so you want to worry about

that one of the died particular have

become inflamed so much that they can

cause obstruction of the large intestine

other associated gas

symptoms include alterations in bowel

habit these include constipation and/or

diarrhea so you can see issues with

bowel movements along with the abdominal

pain other signs and symptoms include

urinary frequency urgency in this area

you might be thinking why does this

happen well if we can see a picture here

if we have a sigmoid colon here the

bladder here if you have a diverticula

that becomes very inflamed in the

sigmoid colon the inflamed diverticulum

and when it pushes against the bladder

it's going to make the person feel like

they need to urinate so they're gonna

have urinary frequency urgency and it

can even cause some burning sensation as

well and because there might be some

micro perforation there might be some

fecal matter exiting through the

diverticula they can become febrile and

tachycardic the complications of

diverticulitis occur in approximately

15% of acute diverticulitis patients

these again include perforation

generally with peritonitis and abscess

forming so if you think you've got a

perforation of one of those die

particulate there are a weakened wall

they're not as strong as the surrounding

bowel wall so they can be weak and they

can essentially pop a hole in them

leading to fecal matter exiting and

causing a potential abscess to form

fistula so fistula is an epithelial eyes

tract between one epic a layer and

another and what happens is in this

picture if a diverticula in the sigmoid

colon is inflamed and push against the

bladder the inflamed diverticulum can

lead to officially forming between the

sigmoid colon in the bladder and in fact

the bladder is a common site for

official to form so fistula again is

attract between the colon in the bladder

it can happen in other areas as well you

might have a fistula between the colon

in the skin or colon in other areas as

well but generally speaking the bladder

is commonly involved so again the fish

Allah can connect the large intestine to

the bladder in as we mentioned before

sometimes a diverticula it becomes so

enflamed it can lead to obstruction of

the large intestine how do I make the

diagnosis of diverticulitis the

diagnosis of our particular itis is

suspected when we see those

characteristic abdominal

tenderness so left lower quadrant pain

they're very tender in that area they

have constant pain with associated

changes in bowel habits and they might

be febrile and tachycardic we're gonna

think about diverticulitis if you were

to do blood work you might also see

leukocytosis so an increase in the white

blood cell count but what I really want

you to take away from this is that doing

a CT scan with IV contrast is required

to confirm the diagnosis of acute

diverticulitis and this is also required

to ensure there are no other

complications we talked about before so

if you do a CT scan you can see the

diverticula in the large intestine and

doing a colonoscopy is not recommended

in diverticulitis just because of the

weakened inflamed wall of the

diverticula but if you were to look

inside you would see a pattern like this

so you can see all these out poaching's

here of the diverticula once we make the

diagnosis of diverticulitis we need to

determine the severity of the

diverticulitis this helps us determine

if we need to treat them in hospital or

as an outpatient so the severity is

generally broken down into a couple of

categories either uncomplicated or

complicated and then that's further

broken down into inpatient versus

outpatient so as mentioned before

complicated diverticulitis is an acute

diverticulitis that has any of the

complications like perforation abscess

obstruction or a fistula any of these if

we see any of these on a CT scan this is

inpatient treatment so we admit the

patient and we treat them in hospital if

the patient doesn't have any of these

complications they have uncomplicated

diverticulitis but if they have any of

these other list of conditions if they

have sepsis Micro perforation or a

flagman if there are immunosuppressed

patient for whatever reason they might

have poorly controlled diabetes they use

steroids chronically or they're on some

kind of immunosuppressive treatment or

they have HIV or AIDS or if they have a

fever that's very high generally greater

than 102.5 Fahrenheit over 39 Celsius or

if they have very significant

leukocytosis or if they're very old

greater than 70 or if they're intolerant

of oral intake or they have severe

abdominal pain or peritonitis or they

have failed outpatient treatment so if

they have any of these plus the

uncomplicated diverticulitis we also

want to treat these patients in hospital

as well so again

very big list but just think about if

they're uncomplicated diverticulitis if

they have anything else any other

worrisome factors treat them in hospital

if they have complicated diverticulitis

they're treated in hospital

automatically so if they have

uncomplicated diverticulitis without any

of these other associated issues or

worries then we can treat them as an

outpatient so how do we treat them as an

outpatient if they have uncomplicated

diverticulitis without any of those

other big list of concerns we can treat

them as an outpatient oral antibiotics

for seven to ten days there's a several

options for oral a biotics can use

ciprofloxacin in metronidazole

levofloxacin in metronidazole or

amoxicillin clavulanic and we put them

on a specialized diet so we generally

can put them on two to three days of a

liquid diet liquid diet only then we can

reassess if they're getting better then

we can liberalize their diet so we can

make the diet soft and then slowly

increase it to a regular diet if they're

impatient it's a bit different we start

them on IV antibiotics until they're

stabilized and when what I mean by

stabilized is that I mean there's a

resolution of their abdominal pain and

tenderness you can put them on IV fluids

in pain control as well because you

generally want them NPO so nothing by

mouth they don't eat or drink anything

depending on the severity if they're not

very very severe or if they're not too

bad we might be able to put them on a

liquid diet but generally we put them on

NPO with IV fluids and IV antibiotics

the patient has any of the complications

we need a few extra steps if they have

an abscess if it's large enough we might

be able to use a percutaneous drain so

we can have essentially a drain that is

sucking out that abscess or we can just

put them on IV antibiotics to deal with

the abscess if there's a micro

perforation it's just generally IV

antibiotics if it's an obstruction we

need surgical resection and if it's a

fistula we also need a surgical

resection as well so once we've treated

the patient there are several

considerations later on after after

recovery we want to start the patient on

a low fiber diet and then slowly

increase their fiber intake there is a

risk for recurrence it's generally 20 to

50 percent have recurrent episodes of

diverticulitis so if the patient was on

a conservative therapy if they were only

treated by diet and oral antibiotics 30

percent of them remain asymptomatic

there are other associated issues as

well as much as 20% of patients can have

chronic abdominal pain so even after the

diverticulitis has resolved 20% of them

can have chronic abdominal pain and a

lot of times this can be mistaken for or

attributed to irritable bowel syndrome

so it can appear like an irritable bowel

syndrome and I also want to mention here

that a hemicolectomy so a partial

removal of the large intestine can be

undertaken to remove the troublesome

portion of the large intestine that

contains the diverticula if the patient

has frequent recurrences of

diverticulitis or they never fully

resolve if they have been treated in

patient their pain never goes away

they're still febrile they still have

leukocytosis the surgery can then be

considered so I wanted to mention that

here I didn't talk about it specifically

but there is a time when surgery can be

undertaken if there are recurrent

episodes of diverticulitis or if a

episode of diverticulitis doesn't

resolve so if you want to learn more

about other medical conditions please

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