by Robert Fusco, M.D.

Diverticulosis… Diverticulitis… OK, what’s the difference?

Every day in my office I am asked this question. Although most adults have heard these common medical terms, they may not really understand what they mean - and mistakenly may use these terms interchangeably. They are not the same. Your Intestines Feed You To understand the difference, it is first necessary to know a bit about the anatomy and function of your intestines. All the food you eat must first be liquefied by the powerful acid within your stomach and then pumped down into your intestinal tract for digestion.

There are two intestines. First comes the narrower, but longer (20 feet) small intestine. The second is the wider, but much shorter (6 feet) large intestine, or colon. The last six inches of the large intestine is called the rectum. Complex food molecules are broken down and their nutrition absorbed in the small intestine. After this process is complete, the remaining liquid waste enters the colon. Amazingly, between the fluids we consume and the secretions of the small intestine, about two gallons of liquid waste enters the colon each day. While the small intestine’s job is to absorb nutrition, the colon acts more like a water treatment plant. Here the excess water is purified and recycled back into the blood stream.

The remaining solid waste, or stool, eventually enters the rectum where it is stored until it is convenient to have a bowel movement. Thus, the small intestine feeds us, and the colon recycles excessive water to prevent dehydration.

What is Diverticulosis?

Diverticulosis is a condition, rather than a disease. It affects the large intestine, or colon. The normal colon is a strong muscular tube and the walls are relatively smooth. A colon affected by diverticulosis has weak spots in the walls. These defects allow the development of balloon-like sacs or outpouches which project on the outside of the colon - much like a bubble forming on a worn inner tube. These hollow pouches, about the size of a small pea, can occur anywhere in the colon, but 80% are found in the sigmoid colon, just above the rectum. This is because that is where the colon is the narrowest and the inner pressure the highest. The mere presence of these pouches on the colon is called diverticulosis.

Who Gets Diverticulosis?

Diverticulosis is a common condition affecting both men and women. Since diverticulosis takes so long to develop, it usually appears later in life. In fact, when you start getting closer to the age of 60, more Americans have it than not. This disorder is mostly one of Western society. Many researchers feel that our typical low fiber American diet is primarily responsible for the high incidence of diverticulosis in this country. In countries such as Africa or India where the diet consists of grains very high in dietary fiber, the condition is almost unheard of.

How is Diverticulosis Diagnosed?

Because there are usually no symptoms, diverticulosis is often discovered during an medical examination performed for other reasons. This may include tests such as a barium enema X-ray, CT scan of the abdomen, flexible sigmoidoscopy, or a colonoscopy examination. The latter two tests are performed through the rectum with a lighted flexible “scope,” and can directly view the colon from the inside providing additional information about the problem. Sometimes, diverticulosis is an incidental finding at surgery or autopsy. If graphic images don’t bother you, click HERE to see what diverticulosis looks like during an autopsy. Look Inside My Colon All of our doctors and nurse practitioner have had a screening colonoscopy examination. In fact, seven years ago at age 50, I had my first colonoscopy. Guess what Dr. Stanley found in my colon? Diverticulosis, of course. I have it in my sigmoid colon like many people my age.

The modern colonoscope is an amazing machine. Built into the tip is a miniature digital camera which can be used to capture still images for your medical record. There is also a digital video camera which can capture video footage of what the doctor sees during the exam.

Complications of Diverticulosis Considering how many millions of Americans have diverticulosis, it is remarkable that so few people are affected by complications. In fact, most people with diverticulosis experience no symptoms at all. However, complications do occur and can be serious. There are three scenarios when diverticulosis can become a problem - abdominal pain, rectal bleeding, and diverticulitis. Abdominal Pain Most diverticular pouches are painless. However, if you have enough of them, they can cause thickening and narrowing of the sigmoid colon. This results in painful spasms in the lower left part of the abdomen. When diverticulosis is far advanced, the lower colon may become narrowed and distorted. When this occurs, there may be thin or pellet-shaped stools, persistent bouts of constipation, and an occasional rush of diarrhea.

Rectal Bleeding Rarely, bleeding occurs from a ruptured blood vessel in one of the pouches. Diverticular bleeding is not subtle. It is usually a significant hemorrhage with a gush of red blood from the rectum or maroon-colored stools. It is not just a little bit of smearing of blood that might come from a hemorrhoid. Fortunately, the bleeding is usually self-limited and stops on its own, but requires careful evaluation and usually a brief hospitalization. Occasionally, emergency surgery is necessary to stop the loss of blood.

Diverticulitis

Diverticulitis is a complication of diverticulosis. It is just a matter of semantics. In medicine, the suffix “-itis,” at the end of a word refers to something that is inflamed or infected. Common examples would be tonsillitis, appendicitis, ulcerative colitis, pancreatitis, bronchitis, prostatitis, sinusitis, and so on. Diverticulosis simply refers to the presence of these hollow pouches on the colon. But, diverticulitis is the proper term when these pouches become infected or inflamed. The colon is home to many beneficial bacteria which are helpful as long as they stay within the colon. Sometimes, one of the diverticular pouches becomes thin and ruptures allowing bacteria normally contained inside the colon to seep out through the wall and cause infection on the outside of the colon. This infection is called diverticulitis. Diverticulitis can be mild with only slight discomfort in the left lower abdomen - or it can be extreme with much pus and abscess formation, severe tenderness and fever. Nobody knows why “osis” becomes “itis,” but is probably because bacteria normally present in the colon penetrate the thin walled pouches. There is no proven method of prevention.

How About Treatment?

Treatment varies with the situation. If there are no symptoms, treatment for diverticulosis is usually not necessary, but a fiber-rich diet is advisable. When diverticulitis occurs, going on a liquid diet for a few days and oral antibiotics can usually abort a mild attack. In severe cases, patients may need hospitalization and intravenous antibiotics. While most people recover from diverticulitis without surgery, sometimes it is necessary to remove the affected portion of the colon. The healthy ends are then rejoined. The most common reason for surgery is to stop repeated episodes of pain, bleeding, or diverticulitis. When diverticulosis occurs in younger individuals, it is usually a more aggressive problem. Complications are more likely to develop, and many eventually require surgery. Surgery is usually a lifetime cure as it is uncommon for symptoms to return after the diseased segment of colon has been removed. High Fiber Diet As mentioned earlier, an inadequate diet is considered the leading cause of diverticulosis. Most health experts agree that the lack of fiber and bulk in the diet is the major cause of chronic constipation and diverticular disease. As our foods are becoming more highly refined, more of us are suffering from symptoms of diverticular disease. Once diverticula have formed there is no way to reverse the process. The pouches are there for the rest of your life. Chances are good that you are not getting enough fiber in your diet. In fact, most people in the United States average only 10 to 15 grams of dietary fiber a day. Most dietitians use 35 grams of fiber a day as the minimum benchmark for a high-fiber diet. Adding fiber and bulk to your diet helps promote regular bowel function and is very important in controlling and minimizing this disease. Foods rich in fiber, such as bran cereals, whole wheat breads, a variety of beans, and fresh fruits and vegetables help keep the stools soft and bulky. Another good source of dietary fiber are the over-the-counter fiber supplements such as Metamucil, Citrucel, Fibercon, and Benefiber. One or two doses a day are very helpful. Preference is mostly a matter of taste. We all should make an effort to include more fiber in our diet, but, don’t be too enthusiastic. That is, do not add too much fiber too soon. Otherwise, troublesome side effects, such as increased gas and bloating, may occur. The golden rule regarding fiber is to go slow. Start with small amounts and gradually increase the extra fiber in your diet.

How About Seeds?

Many patients ask about seeds. For many years it has been suspected that large seeds (apple seeds, orange pits, watermelon seeds, grape pits, etc.) may become trapped in the pouches and can occasionally cause problems. There is no medical evidence to support this theory, but is has not been studied in a scientific fashion. This is mostly an “old wive’s tale,” but we still tell patients who have had one or more of the complications of diverticulosis to remove these seeds. Smaller soft seeds seem to be harmless. Foods such as nuts and popcorn should be chewed very well to avoid problems.

The following list shows various categories of foods that are high in dietary fiber. The examples given for each category are not all inclusive and similar foods may be substituted. You should try to include foods from each group in your daily diet:

Grain Products: high fiber breads, buns, bagels, and muffins made from whole wheat flour Bran Flakes, All Bran, Shredded Wheat, Shredded Wheat ‘n Bran Brown rice, whole-grain pastas

Fruits: dried fruits (apricots, dates, prunes, raisins), blackberries, blueberries, raspberries, strawberries, apples, pears, oranges

Vegetables: broccoli, peas and beans (e.g. kidney, lima beans, chick peas, lentils and soybeans), corn