Diverticular disease involves pouches or sacs that protrude from the intestinal wall. Diverticulosis refers to the presence of diverticula without inflammation. Diverticulitis occurs when diverticula become inflamed, usually due to infection. Risk factors include older age and low-fiber diets. Symptoms include abdominal pain, changes in bowel habits, and fever. Treatment depends on severity and may involve antibiotics, drainage of abscesses, or surgery to remove the affected colon segment. Complications can include abscesses, fistulas, obstruction, or generalized peritonitis.

1. Diverticular Disease
Suman Raj Baral

2. • An abnormal pouch, abnormal sac or pouch protruding from the wall
of a hollow organ.
True Vs False Diverticulum
Contains all layers
of Intestine
Lacks a portion of
normal bowel wall

3. Occurring in human colon are protrusion of mucosa through
muscular layers of the intestine
Termed as pseudodiverticula

4. Nomenclature
• Diverticulum = sac-like protrusion of the colonic wall
• Diverticulosis = describes the presence of diverticuli
• Diverticulitis = inflammation of diverticuli

5. Risk Factors
• Rare in individuals before 30 , but at least 2/3rd of Americans develop
diverticulitis by 80 years
• Postulated that decreased consumption of unprocessed cereals and
increased consumption of sugar and meat are responsible factors for
diverticulitis
• Incidence increases with increasing age

6. Lifestyle factors associated with
diverticular disease
 Low fiber  diverticular disease
 Not absolutely proven in all studies but strongly suggested
 Western diet is low in fiber with high prevalence of
diverticulosis
 In contrast, African diet is high in fiber with a low prevalence
of diverticulosis

7. Pathophysiology
• Diverticuli develop in ‘weak’ regions of the colon. Specifically, local hernias
develop where the vasa recta penetrate the bowel wall
• Most commonly confined to Sigmoid colon in 50% of diverticulosis
followed by 40 % in Descending Colon, and entire colon in 5-10% of cases.
 Usually characterized by muscular thickening of Sigmoid Colon

8. Mucosa
Submucosa
Muscularis
Serosa
Vasa recta

9. Pathophysiology
 Law of Laplace: P = kT / R
 Pressure = K x Tension / Radius
 Sigmoid colon has small diameter resulting in highest
pressure zone

10. Pathophysiology
• Segmentation = motility process in which the segmental muscular contractions
separate the lumen into chambers
• Segmentation  increased intraluminal pressure  mucosal herniation 
Diverticulosis
• May explain why high fiber prevents diverticuli by creating a larger diameter colon and less
vigorous segmentation

11. DIVERTICULITIS
• Result of perforation of colonic diverticulum
• Misnomer- actually an extraluminal pericolic infection caused by
extravasation of faeces through the perforated diverticulum
• Mostly involved is Sigmoid Colon

12. Clinical Features
Symptoms
• Left lower quadrant abdominal pain radiating to left groin or back
• Alteration in bowel habit
• Fever, chills and urinary urgency

13. Physical Findings
• Depends on Site of perforation, amount of contamination, and
presence or absence of secondary infection of adjacent organs
• Tenderness over left lower abdomen, tender mass suggestive of
abscess
• Abdominal Distension if a/w ileus or obstruction
• Rectal/vaginal examination may reveal pelvic abscess

14. Diagnosis
• Four diagnostic modalities considered
• CECT abdomen- reveals location of infection, extent of inflammatory
process, presence and location of abscess, sympathetic involvement of
other organs, secondary complications such as ureteral obstruction or
a fistula to a bladder
• CT guided drainage of abscess can be done.

15. • USG Abdomen/pelvis :Percutaneous drainage under USG guidance
• Barium Enema- no significant role- water soluble can be used- no
chances of barium fecal peritonitis
• MRI

16. Described as broad clinical spectrum of disease
process
Hinchey Stage
I pericolic abscess
II retroperitoneal or pelvic abscess
III purulent peritonitis
IV fecal peritonitis

17. Uncomplicated Diverticulitis

18. • May be treated with antibiotics if not associated with abscess, fistula
formation
• Avoid morphine
• Usually antibiotics respond within 48 hrs
• Once symptoms subside, other investigations to be carried out to rule
out carcinoma – Colonoscopy
• Barium Enema- delineates the extent of disease but cancerous lesions
may be missed as they may be hidden within contrast filled diverticula

19. • 1st attack- treat with high fibers
• 2nd attack- chances are low with less than 25%
• Treat younger patients as per the older patients of above 50 .
• Recurrent attacks- Surgical management to be considered
• Sigmoidectomy to be considered after 2 uncomplicated attacks
• However, no significant difference in mortality and morbidity between 1-2
attacks vs multiple attacks
• Immunocompromised Patients- Selective Colectomy after single attack
• Laparascopic Approach better than midline approach- less hospital stay

20. Complicated Diverticulitis
• Usually confined to pelvis
• Pelvic abscess presents with pain, fever, and leucocytosis
• Abdominal/pelvic/rectal examination : reveals tender, fluctuant mass
• CT/MRI/USG- confirms the diagnosis

21. • USG/CT guided percutaneous drainage if the size is greater than 2 cm
• Occasionally, drained by transanal approach into rectum along with IV
antibiotics
• Elective surgery after 6 weeks- thickened part of sigmoid to be
removed followed by colo-rectal anastomosis
• If diverticula is present throughout the colon, it’s mandatory just to
remove the sigmoid colon rather than all segment of colon

22. Fistula
• May occur between sigmoid colon and skin, bladder, vagina or small
bowel
• Most common cause for fistula between colon and bladder
• Sigmoid-vesicular fistula more common in men than women

23. Symptoms
• Pneumaturia, Fecaluria, recurrent UTI
• Prostatic hypertrophy in men with distal urinary tract obstruction
• CT – demonstrates air in the bladder
• Cystoscopy reveals cystitis and bullous edema at site of fistula and aso
helpful to r/o bladder cancer
• Colonoscopy- examine sigmoid mucosa and exclude colon cancer or
Crohn’s Disease

24. • Treatment : control infection and inflammation- Antibiotics
• One Stage Operation : taking down fistula and excising sigmoid colon
and anastomosis between sigmoid colon and rectum
• Bladder defect need not be closed as it heals spontaneously after
drainage with foley catheter for 7 days
• Large defects may require suturing with drainage

25. Generalized Peritonitis
• Usually two causes
Perforated Diverticulum : peritoneal contamination with faeces
Abscess rupture : contamination with pus in peritoneal cavity
• Ultimately leads to generalized peritonitis
• Presentation : Diffuse abdominal tenderness, with guarding
Elevated WBC, fever, tachycardia, hypotension

26. • Treatment : Immediate Laparatomy with excision of diseased segment
with colostomy using non inflammed descending colon – Hartmann’s
Procedure
• IV antibiotics
• Taking down colostomy after 10 weeks – anastomosing between
descending colon and rectum

27. Obstruction
• Via two mechanism :
• Stricture :
• narrowing of sigmoid because of muscular hypertrophy of the bowel wall
• Difficult to differentiate from malignant stricture
• Treated with Sigmoidectomy
• Small Bowel Obstruction : due to adherence to phlegmon or abscess

28. Diverticular associated Colitis
• Rectal Sparing is the associated finding to differentiate from UC
however confounded with Crohn’s Colitis
• Characterized by prolapse of mucosa associated with diverticula,
hyperplasia of the glands, and muscularization of lamina propria
• Erosions and hemosiderin deposition may mimic UC/CD
• C/F: Tenesmus, hematochezia, diarrhoea
• Colonoscopy – focal erythema, submucosal ecchymosis, erosions and
ulcers

29. • Thank You