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Diverticulosis and diverticulitis Information for patients from the Colorectal Surgery Department, William Harvey Hospital Ashford What is it? Many people have small pouches in their colons that bulge outwards through weak spots, similar to an inner tube that pokes through weak places in a tire. Each pouch is called a diverticulum. Pouches (plural) are called diverticula. The condition of having diverticula is called diverticulosis. About 10 percent of people over the age of 40 have diverticulosis. The condition becomes more common as people age. About half of all people over the age of 60 have diverticulosis and 80 percent of people over the age of 80 have this condition. When the pouches become infected or inflamed, the condition is called Diverticulitis. This occurs in 10 or 25 percent of people with diverticulosis. Diverticulosis and diverticulitis are also known as diverticular disease. What causes diverticular disease? Although not proven, the commonly held view is that a low-fibre diet is the main cause of diverticular disease. Many processed foods contain refined, low-fibre flour. Unlike whole-wheat flour, refined flour has no wheat bran. Diverticular disease is common in developed or industrialised countries - particularly the United States, England, and Australia - where low-fibre diets are common. The disease is rare in the countries of Asia and Africa, where people eat high-fibre vegetable diets. Fibre is the part of fruits, vegetables, and grains that the body cannot digest. Some fibre dissolves easily in water (soluble fibre). It takes on a soft, jelly-like texture in the intestines. Some fibre passes almost unchanged through the intestines (insoluble fibre). Both kinds of fibre help make stools soft and easy to pass. Fibre also prevents constipation. What are the symptoms? Diverticulosis Most people with diverticulosis do not have any discomfort or symptoms. However, possible symptoms may include mild cramps, bloating, and constipation. Other diseases such as irritable bowel syndrome (IBS) and stomach ulcers cause similar problems, so these symptoms do not always mean a person has diverticulosis. You should visit your doctor if you have these symptoms. Diverticulitis The most common symptoms of diverticulitis is abdominal pain. The most common sign is tenderness around the left side of the lower abdomen. If infection is the cause, fever, nausea, vomiting, chills, cramping, and constipation may occur as well. The severity of symptoms depends on the extent of the infection and complications. What are the complications? Diverticulitis can lead to bleeding, infections, perforations, tears, or blockages. These complications always require treatment to prevent them from progressing and causing serious illness. Bleeding Bleeding from diverticula is a rare complication. When diverticula bleed, blood may appear in the toilet or in your stool. Bleeding can be severe, but it may stop by itself and not require treatment. Bleeding diverticula are caused by a small blood vessel in a diverticulum that weakens and finally bursts. If you have bleeding from the rectum, you should see your doctor. If the bleeding does not stop, surgery may be necessary. Abscess, perforation, and peritonitis The infection causing diverticulitis often clears up after a few days of treatment with antibiotics. If the condition gets worse, an abscess may form in the colon. An abscess is an infected area with pus that may cause swelling and destroy tissue. Sometimes the infected diverticula may develop small holes, called perforations. These perforations allow pus to leak out of the colon into the abdominal area. If the abscess is small and remains in the colon, it may clear up after treatment with antibiotics, the doctor may need to drain it. To drain the abscess, the doctor uses a needle and a small tube called a catheter. The doctor inserts the needle through the skin under a local anaesthetic and drains the fluid through the catheter. This procedure is called percutaneous catheter drainage. Sometimes surgery is needed to clear the abscess and, if necessary, remove part of the colon. A large abscess can become a serious problem if the infection leaks out and contaminates areas outside the colon. Infections that spread into the abdominal cavity are called peritonitis. Peritonitis requires immedaite surgery to clean the abdominal cavity and to remove the damaged part of the colon. Without surgery, peritonitis can be fatal. 2 Fistula A fistula is an abnormal connection of tissue between two organs or between an organ and the skin. When damaged tissues come into contact with one another during infection, they sometimes stick together. If they heal that way, a fistula forms. When diverticulitis-related infections spread outside the colon, the colon tissue may stick to other nearby tissues. The organs usually involved are the bladder, small intestine, and skin. The most common type of fistula occurs between the bladder and the colon. It affects men more than women. This type of fistula can result in a severe, long-lasting infection of the urinary tract. The problem can be corrected with surgery to remove the fistula and the affected part of the colon. Intestinal obstruction The scarring caused by infection may cause partial or total blockage of the large intestine. When this happens, the colon is unable to move bowel contents normally. When the obstruction totally blocks the intestine, emergency surgery is necessary. Partial blockage is not an emergency, so the surgery to correct it can be planned. How does the doctor diagnose diverticular disease? To diagnose diverticular disease, the doctor will ask about the medical history, perform a physical examination, and may perform one or more diagnostic tests. As most people do not have symptoms, diverticulosis is often found through tests ordered for another ailment. When taking a medical history, the doctor may ask about bowel habits, symptoms, pain, diet, and medications. The physical examination usually involves a digital rectal examination. To perform this test, the doctor inserts a gloved, lubricated finger into the rectum to detect tenderness, blockage, or blood. The doctor may check stools for signs of bleeding and test blood for signs of infection. The doctor may also order x-rays or other tests. What is the treatment for diverticula disease? A high-fibre diet and occasionally, mild pain medications will help relieve symptoms in most cases. Sometimes an attack of diverticulitis is serious enough to require a hospital stay and possibly surgery. Diverticulosis Increasing the amount of fibre in the diet may reduce symptoms of diverticulosis and prevent complications such as diverticulitis. Fibre keeps stools soft and lowers pressure inside the colon so that bowel content can move through easily. Twenty to 35 grams of fibre is recommended daily. The table on the next page shows the amount of fibre in some foods that you can easily add to your diet. The doctor may also recommend taking a fibre product such as Fybogel once a day. These products are mixed with water and provide about two to 3.5 grams per tablespoon, mixed with eight ounces of water. Fybogel and Psyllium seed products are available in pharmacies. Until recently, many doctors suggested avoiding foods with small seeds such as tomatoes or strawberries because they believed that particles could lodge in the diverticula and cause inflammation. However, it is now generally accepted that only foods that may irritate or get caught in the diverticula cause problems. Foods such as nuts, popcorn hulls, and sunflower, pumpkin, caraway, and sesame seeds should be avoided. The seeds in tomatoes, courgettes, cucumbers, strawberries, and raspberries, as well as poppy seeds, are generally considered harmless. People differ in the amounts and types of foods they can eat. Decisions about diet should be made based on what works best for each person. Keeping a diary may help identify individual items in the diet. 3 If cramps, bloating, and constipation are problems, the doctor may prescribe a short course of pain medication. However, many medications affect emptying of the colon, an undesirable side effect for people with diverticulosis. Amount of fibre in some foods Breakfast cereals All-Bran Shredded Wheat Bran Flakes Weetabix Muesli (no added sugar) Muesli (swiss style) Fruit ‘n’ Fibre Porridge (milk or water) Cornflakes Typical portion (weight) 1 medium sized bowl (40g) 2 pieces (44g) 1 medium sized bowl (30g) 2 pieces (37.5g) 1 medium sized bowl (45g) 1 medium sized bowl (45g) 1 medium sized bowl (40g) 1 medium sized bowl (250g) 1 medium sized bowl (30g) Fibre/portion 9.8grams 4.3grams 3.9grams 3.6grams 3.4grams 2.9grams 2.8grams 2.3grams 0.3grams Bread/rice/pasta Crispbread (rye) Pitta bread (wholemeal) Pasta (plain, fresh cooked) Wholemeal bread Naan bread Brown bread Granary bread Brown rice (boiled) White bread White rice (boiled) Typical portion (weight) 4 crispbread (36g) 1 piece (75g) 1 medium portion (200g) 2 slices (70g) 1 piece (160g) 2 slices (70g) 2 slices (70g) 1 medium portion (200g) 2 slices (70g) 1 medium portion (200g) Fibre/portion 4.2grams 3.9grams 3.8grams 3.5grams 3.2grams 2.5grams 2.3grams 1.6grams 1.3grams 0.2grams Vegetable Baked beans Red kidney beans Peas (boiled) French beans (boiled) Brussel sprouts (boiled) Potatoes (old, boiled) Spring greens (boiled) Carrots (boiled/sliced) Broccoli (boiled) Spinach (boiled) Typical portion (weight) Half can (200g) 3 tablespoons (80g) 3 heaped tablespoons (80g) 4 heaped tablespoons (80g) 8 sprouts (80g) 1 medium size (200g) 4 heaped tablespoons (80g) 3 heaped tablespoons (80g) 2 spears (80g) 2 heaped tablespoons (80g) Fibre/portion 7.4grams 5.4grams 3.6grams 3.3grams 2.5grams 2.4grams 2.1grams 2.0grams 1.8grams 1.7grams 4 Salad vegetables Pepper (capsicum green/red) Onions (raw) Olives (in brine) Tomato (raw) Lettuce (sliced) Typical portion (weight) Half (80g) 1 medium (80g) 1 heaped tablespoon (30g) 1 medium / 7 cherry (80g) 1 bowl (80g) Fibre/portion 1.3grams 1.1grams 0.9grams 0.8grams 0.7grams Fruit Avocado pear Pear (with skin) Orange Apple (with skin) Raspberries Banana Tomato juice Strawberries Grapes Orange juice Typical portion (weight) 1 medium (145g) 1 medium (170g) 1 medium (160g) 1 medium (112g) 2 handfuls (80g) 1 medium (150g) 1 small glass (200ml) 7 strawberries (80g) 1 handful (80g) 1 small glass (200ml) Fibre/portion 4.9grams 3.7grams 2.7grams 2.0grams 2.0grams 1.7grams 1.2grams 0.9grams 0.6grams 0.2grams Dried fruit/nuts Apricots (semi-dried) Prunes (semi-dried) Almonds Peanuts (plain) Mixed nuts Brazil nuts Raisins/sultanas Typical portion (weight) 3 whole (80g) 3 whole (80g) 20 nuts (33g) 1 tablespoon (25g) 1 tablespoon (25g) 10 nuts (33g) 1 tablespoon (25g) Fibre/portion 5.0grams 4.6grams 2.4grams 1.6grams 1.5grams 1.4grams 0.5grams Other food Quorn (pieces) Chicken curry (takeaway) Vegetable pasty Bran (wheat) Potato crisps (low fat) Pakora/bhajia (vegetable) Pizza (cheese and tomato) Typical portion (weight) 1 serving (100g) 1 portion meat/sauce (150g) 1 medium sized (150g) 1 tablespoon (7g) 1 bag (35g) 1 portion (50g) 1 slice, deep pan (80g) Fibre/portion 4.8grams 3.0grams 3.0grams 2.5grams 2.1grams 1.8grams 1.8grams Diverticulitis Treatment for diverticulitis focuses on clearing up the infection and inflammation, resting the colon, and preventing or minimising complications. An attack of diverticulitis without complications may respond to antibiotics within a few days if treated early enough. To help the colon rest, the doctor may recommend bed rest and a liquid diet, along with pain relief. 5 When is surgery necessary? If attacks are severe or frequent, the doctor may advise surgery. The surgeon removes the affected part of the colon and joins the remaining sections. This type of surgery is called colon resection, and aims to keep attacks from coming back and prevents complications. The doctor may also recommend surgery for complications of a fistula or intestinal obstruction. If antibiotics do not correct an attack, emergency surgery may be required. Other reasons for emergency surgery include a large abscess, perforation, peritonitis, or continued bleeding. Emergency surgery usually involves two operations. The first surgery will clear the infected abdominal cavity and remove part of the colon. Because of infection and sometimes obstruction, it is not safe to rejoin the colon during the first operation. Instead, the surgeon creates a temporary hole, or stoma, in the abdomen. The end of the colon is connected to the hole, a procedure called colostomy, to allow normal eating and bowel movements. The stool goes into a bag attached to the opening in the abdomen. In the second operation, the surgeon rejoins the ends of the colon. Points to remember • Diverticulosis occurs when small pouches, called diverticula, bulge outward through weak spots in the colon (large intestine). • The pouches form when pressure inside the colon builds, usually because of constipation. • Most people with diverticulosis never have any discomfort or symptoms. • The most likely cause of diverticulosis is a low fibre diet because it increases the likelihood of constipation and pressure inside the colon. • For most people with diverticulosis, eating a high-fibre diet is the only treatment required. • You can increase your fibre intake by eating foods such as whole grain breads and cereals; fruit like apples and peaches; vegetables like kidney beans and lima beans. • Diverticulitis occurs when the pouches become infected or inflamed and cause pain and tenderness around the left side of the lower abdomen. Additional readings • Diverticular disease. In: Corman ML, Allison SI, Kuehne JP. Handbook of colon and rectal surgery. Hagerstown, MD: Lippincott, Williams and Wilkins. 2002; 637-653. • Diverticular disease. In: King JE, ed. Mayo Clinic on Digestive Health. Rochester, MN: Mayo Clinic. 2000; 125-132. • Marcello PW. Understanding diverticular disease. Ostomy Quarterly. 2002: 39(2); 56-57. • http://www.nlm.nih.gov/medlineplus/diverticulosisanddiverticulitis.html 6 Any complaints, comments, concerns, or compliments If you have other concerns please talk to your doctor or nurse. Alternatively please contact our Patient Advice and Liaison Service (PALS) on 01227 783145 or 01227 864314, or email [email protected] Further patient information leaflets In addition to this leaflet, East Kent Hospitals has a wide range of other patient information leaflets covering conditions, services, and clinical procedures carried out by the Trust. For a full listing please go to www.ekhuft.nhs.uk/patientinformation or contact a member of staff. After reading this information, do you have any further questions or comments? If so, please list below and bring to the attention of your nurse or consultant. Would you like the information in this leaflet in another format or language? We value equality of access to our information and services and are therefore happy to provide the information in this leaflet in Braille, large print, or audio - upon request. If you would like a copy of this document in your language, please contact the ward or department responsible for your care. Pacjenci chcący uzyskać kopię tego dokumentu w swoim języku ojczystym powinni skontaktować się z oddziałem lub działem odpowiedzialnym za opiekę nad nimi. Ak by ste chceli kópiu tohto dokumentu vo vašom jazyku, prosím skontaktujte nemocničné pracovisko, alebo oddelenie zodpovedné za starostlivosť o vás. Pokud byste měli zájem o kopii tohoto dokumentu ve svém jazyce, kontaktujte prosím oddělení odpovídající za Vaši péči. Чтобы получить копию этого документа на вашем родном языке, пожалуйста обратитесь в отделение, ответственное за ваше лечение. We have allocated parking spaces for disabled people, automatic doors, induction loops, and can provide interpretation. For assistance, please contact a member of staff. This leaflet has been produced with and for patients Information produced by Mr Nagesh Rao, Colo-rectal surgeon and team Date reviewed: March 2015 Next review date: March 2017 EKH104