Diverticular disease and diverticulitis
With the years the wall of the large bowel stops being a smooth tube: small pouches the size of a pea push outwards from it, and those are diverticula.
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Medicines commonly prescribed for Diverticular disease and diverticulitis
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 875/125 mg/mgActive substance: amoxicillin and beta-lactamase inhibitorManufacturer: Aurovitas Spain, S.A.U.Prescription requiredDosage form: TABLET, 875 mg/125 mgActive substance: amoxicillin and beta-lactamase inhibitorManufacturer: Almus Farmaceutica S.A.U.Prescription requiredDosage form: ORAL SOLUTION/SUSPENSION, 1000 mgActive substance: amoxicillinManufacturer: Laboratorio Reig Jofre, S.A.Prescription required
With the years the wall of the large bowel stops being a smooth tube: small pouches the size of a pea push outwards from it, and those are diverticula. On their own they are not yet a disease, and most people have them by their sixties without knowing it and without ever finding out. The conversation starts when the pouches begin to hurt or to become inflamed. It is worth separating three situations from the outset, because very different things hide behind similar words, from a harmless incidental finding to an operation that cannot wait.
Where the pouches in the bowel wall come from
The muscular layer of the bowel is not continuous: wherever the vessels that feed it pass through, a weak point is left behind. When the pressure inside the bowel rises, the lining is squeezed out through those openings much as an inner tube bulges through a split in a tyre. That is how a diverticulum forms, and in essence it is a hernia of the inner lining.
What raises that pressure and encourages the process:
- too little fibre in the diet, since hard dry stool has to be pushed along with far more effort;
- age, because the tissues lose their spring and past sixty diverticula are found in most people who are examined;
- excess weight, smoking, sitting still and the regular use of anti-inflammatory painkillers;
- inheritance: in some people the connective tissue is weaker to begin with.
The three situations that need keeping apart:
- Diverticulosis: the pouches are there and there are no symptoms. It is an incidental finding and needs no treatment.
- Diverticular disease: the pouches cause symptoms, but nothing is inflamed.
- Diverticulitis: something has become trapped in a pouch and the wall has become inflamed. This is already an acute illness, with fever and severe pain.
How it shows itself
In Europe the pouches sit almost always in the lower left part of the abdomen, in the sigmoid colon, which is where the characteristic left-sided pain comes from. Less often they sit on the right, and then the picture misleads: pain in the right side of the abdomen with a fever is far more often taken for appendicitis, and the answer comes from the scan.
In diverticular disease without inflammation the complaints run like this:
- a dull or gripping pain low down on the left, usually after eating, which eases after opening the bowels or passing wind;
- bloating and a feeling of not having finished;
- constipation, loose stools, or the two taking turns;
- sometimes traces of blood in the stool.
In diverticulitis the picture is different and considerably worse: the pain is constant, severe and fixed in one spot, and fever, shivering, nausea and an abrupt change in bowel habit come with it. The area hurts when pressed. This does not settle by itself, and it needs dealing with on the day it appears.
Diverticular bleeding stands apart and behaves quite unlike inflammation: it comes on suddenly, without pain or fever, the amount of blood is substantial from the first, and it is dark red or wine-coloured, often with clots. It usually stops on its own, but the quantity is frightening and can occasionally be dangerous. Heavy bleeding from the back passage means hospital, whether or not there is any pain.
What has to be ruled out first
This is the most serious part of the whole subject. Half of all older people have diverticula, so it is far too easy to blame them and consider the matter closed. Meanwhile the very same things, abdominal pain, an altered bowel habit and blood, are produced by bowel cancer, which at an early stage is treated well and leaves almost no trace.
Nothing may be put down to diverticula without investigation if any of the following is present:
- blood in the stool, particularly if it happens more than once;
- a bowel habit that has changed and stayed changed for more than a few weeks, with looser, more frequent or narrower stools;
- weight coming off for no reason;
- anaemia found on a blood test, especially iron deficiency;
- symptoms appearing for the first time in later life;
- bowel cancer in the family.
Irritable bowel syndrome and inflammatory bowel disease behave the same way: they cannot be told apart by the sensations alone.
What tests are needed and when
In an acute attack the main investigation is a CT scan of the abdomen. It shows not only the inflamed segment but also what it has turned into: whether there is a collection of pus or a hole in the wall. Whether treatment happens at home or in hospital follows directly from that. A blood test with inflammatory markers goes alongside it.
Colonoscopy is not done during acute inflammation, because an inflamed wall inflated with air can tear. It is put off for roughly six to eight weeks after everything has settled, and only then is the whole colon inspected, primarily to be sure that no tumour was sitting behind the attack. That examination is not worth skipping even if you have felt perfectly well for months.
Between attacks, stool tests may be needed: occult blood and calprotectin, which separates inflammatory bowel disease from an irritable bowel.
How it is treated
In diverticular disease without inflammation the treatment is aimed at the bowel itself: settling the stool and easing the spasm.
- Bulk-forming laxatives, which help equally with constipation and with loose stools, because what they actually do is normalise the consistency.
- Antispasmodics for gripping pain.
- For pain relief, paracetamol.
Uncomplicated diverticulitis in someone without other serious illness is increasingly managed without antibiotics: rest, plenty of fluids, a few days of light food, pain relief, and review to see how things go. Antibiotics are kept for a high fever, marked inflammation on the blood tests, a weakened immune system, serious underlying conditions or signs of complication. That decision belongs to the doctor and rests on the individual picture, not on the name of the diagnosis.
What not to do about abdominal pain in this setting: do not take anti-inflammatory painkillers, meaning ibuprofen and its relatives, or opioid painkillers such as codeine. The first group raises the risk of the bowel wall perforating, and the second slows the bowel and worsens constipation, and with it the pressure inside. This is one of the few situations where the choice of painkiller genuinely changes the outcome.
If attacks keep returning, get in the way of daily life or have left a narrowing behind them, planned surgery to remove the affected segment comes up for discussion. The decision is weighed up with the surgeon, because the operation itself is not a small matter either.
When emergency care is needed
Complications are uncommon but move fast. Pus can collect around an inflamed pouch, the wall can burst into the abdominal cavity and cause peritonitis, and the bowel can narrow until nothing passes. Sometimes a channel forms between the bowel and a neighbouring organ, most often the bladder, and it announces itself with unusual signs: bubbles of gas or traces of stool in the urine, and urine infections that keep coming back.
Call an ambulance (across Europe the single number is 112) or go straight to the emergency department if you, or the person you care for, have:
- severe abdominal pain, especially with a hard, swollen belly, vomiting and no stool or wind passing;
- heavy bleeding from the back passage, or weakness and dizziness while it is happening;
- fever with shivering and pain that keeps building;
- confusion, pale or blotchy skin, a very high or very low temperature, fast breathing or a sharp drop in how much urine is passed, all of which point to sepsis;
- pain that stops you straightening up and worsens with every movement or jolt.
A collection of pus is usually drained through the skin under scan guidance, while a perforation calls for surgery. Sometimes the bowel has to be brought out onto the abdominal wall for a time so that the inflamed segment can heal; in most cases it is joined back up later on.
What depends on food and habits
Diverticula cannot be got rid of, as they do not go away. What can be done is to lower the chance of their becoming inflamed again quite considerably.
- Fibre every day: vegetables, fruit, pulses, wholemeal bread and cereals. It has to be increased gradually, over two or three weeks, or the first days will bring wind and discomfort.
- Water is the compulsory partner of fibre. Without enough to drink, fibre only makes the stool harder.
- Stop smoking: complications are more frequent in smokers.
- Bring the weight down if there is extra, and move regularly, for which walking is enough.
- Talk to the doctor about replacing long-term anti-inflammatory painkillers if you take them for joints or a bad back.
And a word about the prohibition you have almost certainly heard: that nuts, seeds, popcorn and the pips of tomatoes and strawberries lodge in the pouches and set off the inflammation. It is an old idea that was tested in large studies and not borne out, since people who ate nuts had no more attacks and in fact had slightly fewer. There is no need to give them up. There are no forbidden foods in this condition at all, only one general rule: the more plant food there is, the quieter the bowel.
For the first days after an acute attack the diet is lightened for a while, but that is a measure for the duration of the inflammation and not a way of life.
Online consultation
A remote appointment handles everything that does not require a hand on the abdomen at that exact moment: what the tests already done and the scan report mean, whether a colonoscopy is needed and how long after the inflammation to arrange it, how to tell your ordinary bloating from the start of an attack. The doctor helps get the diet and the bowel habit in order, picks pain relief that is safe here instead of the kind best avoided, and explains which changes mean setting off for hospital without waiting. Acute abdominal pain, fever and bleeding are not assessed through a screen: those need examining in person.
This material is for information only and does not replace medical advice.
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