They are commonly called “diverticula“, but this is not always their correct name. When the problem affects the esophagus and in the case of the so-called “Meckel’s diverticulum” (a congenital anomaly of the final part of the small intestine) the term is indeed appropriate, but when they are localized at the level of the colon it would be better to speak of “pseudodiverticula” or “false diverticula“.
What we always have to deal with are small extroflexions of the digestive tract similar to bags, but only in the case of real diverticula are all the layers of the gastrointestinal wall involved.
The “real” diverticula
Observed with an endoscope (a sort of tube associated with a camera with which it is possible to visualize the inside of the gastrointestinal tract) the diverticula appear as real openings on the wall of the digestive tract.
The esophageal ones can be caused by abnormalities in the functioning of the pharynx (Zenker’s diverticula or pharyngeal), by inflammatory lesions or disorders of esophageal motility (mid-esophageal or traction diverticula), or by disorders of the motility of the esophagus (epinephrinic diverticula).
Often this type of diverticulum is asymptomatic and the only disorders that may be present are those triggered by the disorder that has also promoted the formation of diverticula. Zenker’s pumps, however, can fill with food and be associated with regurgitation, pneumonia and, more rarely, difficulty swallowing or forming a mass at the cervical level.
It is generally not necessary to treat esophageal diverticula specifically; rather, it is good to treat the pathology that causes them. However, there are cases in which their surgical removal is indicated.
Meckel’s diverticulum is formed in the fetus during gestation and is present in about 2% of people, with no differences between males and females.
Compared to other “true” diverticula, it has a peculiar characteristic: it can contain typical cells of the stomach or pancreas. In most cases this does not entail particular consequences, but sometimes it can lead to intestinal ulcerations and, consequently, bleeding.
These hemorrhages are more frequent in children under the age of 5 years; In larger ones and adults, occlusions due to invagination of the diverticulum, adhesions, foreign bodies, hernias, torsions (volvules) or tumors are more frequent.
Occlusions are associated with abdominal cramps, nausea and vomiting. A perforation of the diverticulum can cause peritonitis.
Finally, Meckel’s diverticulum can become inflamed, giving rise to diverticulitis (more frequent in older children), or complicated by the appearance of a tumor (a rare and more common consequence in adulthood).
A small asymptomatic Meckel diverticulum can be left where it is without health risks. Occlusions, bleeding, diverticulitis and thickening require surgery.
Pseudodiverticula, diverticulosis and diverticulitis of the colon
Always remaining in the intestine, the frequency of diverticula in the colon is much higher than that of Meckel’s diverticulum. Here, however, as mentioned, those that form are pseudodiverticula.
The presence of one or more of these extroflexions is a condition known as “diverticulosis“, particularly frequent in the elderly population, but increasingly widespread also in people under the age of 45.
Usually diverticula form in the terminal part of the colon or, more rarely, in the rectum; For this reason, the symptoms, if present, appear on the left side of the abdomen. The average size varies between 3 and 10 mm.
In some cases, however, diverticula form in the right side of the colon. Moreover, very rarely their diameter can exceed 4 cm, so as to speak of “giant diverticula”.
In itself, diverticulosis should not be considered a disease. Most inhabitants of Western countries develop diverticula with increasing age, even more than one, but the condition remains asymptomatic in about 80% of cases.
In the presence of symptoms it is instead possible to speak of “diverticular disease“. Usually pain and bleeding are associated with inflammation and bleeding, but diverticulosis can also be associated with nonspecific symptoms in the absence of inflammation, in particular:
- abdominal pain
- abdominal swelling
- diarrhoea
- constipation
- intestinal irregularity
- passage of mucus from the rectum.
When inflammation involves the wall of the intestine and the surrounding tissues, what you are dealing with is diverticulitis. In the absence of perforated abscesses or peritonitis, diverticulitis is called “uncomplicated”. Otherwise we speak of “complicated diverticulitis“.
Diverticulitis can be an acute problem or not resolve completely, turning into a chronic problem. Chronic diverticulitis can also be complicated or uncomplicated, depending on whether or not it is associated with narrowing (which can lead to intestinal obstructions) or fistulas (abnormal communications with other organs, typically those of the urinary tract).
Possible symptoms of colon diverticulitis include:
- pain in the lower (left or, less often, right) part of the abdomen
- tenderness (i.e. painful reaction to maneuvers such as compression) to the lower (left or, less often, right) part of the abdomen
- nausea
- vomit
- fever
- urinary symptoms.
In about 3 out of 4 cases the inflammation remains localized. One patient out of 4, on the other hand, experiences the appearance of abscesses, peritonitis, intestinal occlusions or fistulas.
The presence of any complications can lead to the appearance of other symptoms, such as the presence of feces in the urine, skin infections, abdominal distension and, rarely, bleeding.
Diverticulosis and diverticulitis of the colon: the causes
To cause diverticula is the increase in pressure inside the digestive tract, which would push the mucosa outwards, promoting the appearance of these bags at the level of the points where the muscle tissue of the intestine is weaker.
But why this happens has not yet been fully clarified. What is known is that multiple factors that seem to interact with each other come into play.
On the one hand, environmental factors such as smoking, taking medications (especially non-steroidal anti-inflammatories, corticosteroids and opioids), physical inactivity and nutrition can play a significant role. For example, diverticula formation appears to be associated with insufficient fiber intake and high red meat consumption.
On the other hand, these environmental factors interact with physical characteristics (obesity) and hereditary characteristics and with alterations in the structure or activity of the colon, which in turn favor the onset of diverticula.
As for the inflammation typical of diverticulitis of the colon, it was thought for a long time that it was triggered by the passage of intestinal bacteria through the mucous membrane of the diverticulum. However, this theory has been questioned, leaving the exact mechanisms that trigger the inflammatory phenomena associated with diverticulitis still to be clarified.
How colon diverticula are treated
When it remains asymptomatic, diverticulosis of the colon generally does not require any treatment. Even the food precautions recommended in the past (in particular the invitation to avoid the consumption of seeds, dried fruit, grains and popcorn) are no longer considered necessary.
In the presence of non-specific symptoms, a diet high in fiber may be useful, while any bleeding should be managed like other bleeding of the terminal part of the digestive tract. Often the treatment takes place through an endoscopy; Sometimes angiography can also be useful. Surgery, on the other hand, is reserved for the most difficult cases to treat (for example, in the presence of multiple or persistent bleeding that does not respond to other treatments).
The most suitable treatment in case of diverticulitis of the colon varies depending on the severity of the situation, and there is no lack of conflicting opinions.
In more serious cases, fasting may even be required, while in milder cases a liquid diet may be considered sufficient. At present, however, it is considered possible to avoid changes to the power supply.
Sometimes antibiotics can be prescribed, but today they are used less than in the past. The cases in which they are considered really useful are those of complicated diverticulitis or those of uncomplicated diverticulitis in which the patient is immunocompromised or suffering from sepsis (a blood infection).
Any abscesses, especially if larger than 3 cm, are usually attacked by drainage, but in some cases may require surgery.
Finally, the surgical approach is the solution even in severe cases where perforations, generalized peritonitis and symptoms resistant to non-surgical treatments are present.
Only complicated episodes of diverticulitis that do not resolve completely require periodic check-ups by colonoscopy. In other cases they may not be necessary.
However, the prevalence of colorectal cancer in patients with complicated diverticulitis undergoing conservative treatments (without removal of intestinal portions) varies between 7.9 and 10.8%. For this reason, if not performed in the previous 3 years, these patients may be advised a colonoscopy at least 6 weeks after the acute episode of diverticulitis.
Joycelyn Elders is the author and creator of EmpowerEssence, a health and wellness blog. Elders is a respected public health advocate and pediatrician dedicated to promoting general health and well-being.
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