Diverticular disease and diverticulitis

বৃহদন্ত্রের দেয়ালে ছোট ছোট থলি তৈরি হয়ে সেখানে প্রদাহ দেখা দিলে diverticular disease হয়, এই থলিগুলোকে diverticula বলা হয়। এই থলিগুলোর এক বা একাধিকটিতে সংক্রমণ হলে diverticulitis-এর লক্ষণগুলো দেখা দিতে শুরু করে।

ডাক্তাররা পুরোপুরি নিশ্চিত নন কেন diverticula তৈরি হয়, তবে খাবারে পর্যাপ্ত আঁশ বা ফাইবার না থাকার সাথে এর গভীর সম্পর্ক রয়েছে।

ফাইবার মলকে নরম ও ভারী করে তোলে, যার ফলে মল বের করে দেওয়ার জন্য বৃহদন্ত্রকে খুব বেশি চাপ দিতে হয় না।

মল যখন শক্ত ও ছোট আকারের হয়, তখন বৃহদন্ত্রের ভেতর দিয়ে তা ঠেলে বের করতে বাড়তি চাপের প্রয়োজন পড়ে। এই বাড়তি চাপ অন্ত্রের দেয়ালের বাইরের মাংসপেশির স্তরে কিছু দুর্বল জায়গা তৈরি করতে পারে। সময়ের সাথে সাথে ভেতরের আস্তরণটি (mucosa) এই দুর্বল জায়গাগুলো দিয়ে ফুলে বাইরে বেরিয়ে আসে এবং diverticula নামের ছোট থলি তৈরি করে।

কম ফাইবারযুক্ত খাবার খাওয়ার সাথে diverticula তৈরির এই যোগসূত্রটি ডাক্তারি প্রমাণ দিয়ে পুরোপুরি নিশ্চিত হওয়া যায়নি। তবে যেসব পশ্চিমা দেশে কম ফাইবারযুক্ত খাবার খাওয়ার প্রবণতা বেশি, সেখানে diverticular disease এবং diverticulitis দুটোই অনেক বেশি দেখা যায়, যা এই ধারণাকে সমর্থন করে।

Diverticular disease can be hard to identify from symptoms alone, since other conditions, such as irritable bowel syndrome (IBS), can cause a very similar picture.

As a first step, your doctor may recommend blood tests to rule out other conditions such as coeliac disease (a condition caused by an abnormal immune response to gluten) or bowel cancer.

In some cases, you may be given treatment for IBS and diverticular disease at the same time.

Colonoscopy

To make sure there is not a more serious cause behind your symptoms, your doctor may refer you for a colonoscopy. In this test, a thin tube with a camera at the end (a colonoscope) is inserted into your rectum and guided into your colon. Before the procedure begins, you will be given a laxative to clear out your bowels.

A colonoscopy is not usually painful, but it can feel uncomfortable. You may be offered pain relief and a sedative beforehand to help you feel more relaxed and ease any discomfort.

CT pneumocolon or colonography

Another way of confirming the presence of diverticula is a computerised tomography (CT) scan. A CT scan uses X-rays and a computer to build detailed images of the inside of the body.

As with a colonoscopy, you will be given a laxative to clear out your bowels before the CT scan.

Unlike a regular CT scan, a colonography scan involves a tube being placed into your rectum, which is used to pump a small amount of air in. The scan is then taken once while you lie on your front, and again while you lie on your back.

You may need an injection of contrast dye before the scan, though this is not always necessary.

Treating diverticular disease and diverticulitis

A high-fibre diet can often ease symptoms of diverticular disease, and paracetamol can be used to relieve pain – other painkillers such as aspirin or ibuprofen are not recommended for regular use, as they can cause stomach upsets. Speak to your GP if paracetamol alone is not working.

Mild diverticulitis can usually be treated at home with antibiotics prescribed by your GP. More serious cases may need hospital treatment to prevent and treat complications.

Surgery to remove the affected section of the intestine is sometimes recommended if there have been serious complications, although this is rare.

Read more about treating diverticular disease and diverticulitis.

Treatment options for diverticular disease and diverticulitis depend on how severe your symptoms are.

Who is affected

Diverticular disease is one of the most common digestive conditions.

Both sexes are equally affected by diverticular disease and diverticulitis, although the condition is more likely to appear at a younger age (under 50) in men than in women. Overall, symptoms of diverticulitis are most likely to occur in people over 70 years old.

Diverticular disease is often described as a ‘Western disease’ because the rates are high in European and North American countries, and low in African and Asian countries.

A combination of genetics and diet is thought to be the reason for this and the fact that people in Western countries tend to eat less fibre.

People aged 50 to 70 who eat a high-fibre diet (25g a day) have a 40% lower chance of admission to hospital with complications of diverticular disease – compared to others in their age range with the lowest amount of dietary fibre.

Treatment at home

Mild diverticulitis can often be treated at home. Your GP will prescribe antibiotics for the infection and you should take paracetamol for the pain. It’s important that you finish the complete course of antibiotics, even if you are feeling better.

Some types of antibiotics used to treat diverticulitis can cause side effects in some people, including vomiting and diarrhoea.

Your GP may recommend that you stick to a fluid-only diet for a few days until your symptoms improve. This is because trying to digest solid foods may make your symptoms worse. You can gradually introduce solid foods over the next 2 or 3 days.

For the 3 to 4 days of recovery, a low-fibre diet is suggested, until you return to the preventative high-fibre diet. This is to reduce the amount of faeces (poo) your large bowel has to deal with while it is inflamed.

If you have not been diagnosed with diverticular disease before, your GP may refer you for a test such as a colonoscopy or CT colonography after the symptoms have settled.

Treatment at hospital

If you have more severe diverticulitis, you may need to go to hospital, particularly if:

• your pain cannot be controlled using paracetamol
• you are unable to drink enough fluids to keep yourself hydrated
• you are unable to take antibiotics by mouth
• your general state of health is poor
• you have a weakened immune system
• your GP suspects complications
• your symptoms fail to improve after 2 days of treatment at home

If you are admitted to hospital for treatment, you are likely to receive injections of antibiotics and be kept hydrated and nourished using an intravenous drip (a tube directly connected to your vein). Most people start to improve within 2 to 3 days.

Surgery

In the past, surgery was recommended as a preventative measure for people who had 2 episodes of diverticulitis as a precaution to prevent complications.

This is no longer the case, as studies have found that in most cases, risks of serious complications from surgery (estimated to be around 1 in 100) usually outweigh the benefits.

However, there are exceptions to this, such as:

• if you have a history of serious complications arising from diverticulitis
• if you have symptoms of diverticular disease from a young age (it is thought the longer you live with diverticular disease, the greater your chances of having a serious complication)
• if you have a weakened immune system or are more vulnerable to infections

If surgery is being considered, discuss both benefits and risks carefully with the doctor in charge of your care.

In rare cases, a severe episode of diverticulitis can only be treated with emergency surgery. This is when a hole (perforation) has developed in the bowel. This is uncommon, but causes very severe abdominal pain, which needs an emergency trip to hospital.

Colectomy

Surgery for diverticulitis involves removing the affected section of your large intestine. This is known as a colectomy. There are 2 ways this operation can be performed:

• an open colectomy – where the surgeon makes a large incision (cut) in your abdomen (stomach) and removes a section of your large intestine
• laparoscopic colectomy – a type of ‘keyhole surgery’ where the surgeon makes a number of small incisions in your abdomen and uses special instruments guided by a camera to remove a section of large intestine

Open colectomies and laparoscopic colectomies are thought equally effective in treating diverticulitis, and have a similar risk of complications. People who have laparoscopic colectomies tend to recover faster and have less pain after the operation.

Emergency surgery when the bowel has perforated is more likely to be open and may result in a stoma being formed.

Stoma surgery (‘having a bag’)

In some cases, the surgeon may decide your large intestine needs to heal before it can be reattached, or that too much of your large intestine has been removed to make reattachment possible.

In such cases, stoma surgery provides a way of removing waste materials from your body without using all of your large intestine. It is known as ‘having a bag’ as a bag is stuck to the skin on your belly and the faeces (poo) are collected in the bag.

Stoma surgery involves the surgeon making a small hole in your abdomen – known as a stoma. There are 2 ways this procedure can be carried out.

An ileostomy – where a stoma is made in the right-hand side of your abdomen. Your small intestine is separated from your large intestine and connected to the stoma, and the rest of the large intestine is sealed. You will need to wear a pouch connected to the stoma to collect waste material (poo).

A colostomy – where a stoma is made in your lower abdomen and a section of your large intestine is removed and connected to the stoma. As with an ileostomy, you will need to wear a pouch to collect waste material.

In most cases, the stoma will be temporary and can be removed once your large intestine has recovered from the surgery. This will depend on the situation when you had the operation. If it was an emergency operation, you may need a few months to recover before having surgery to reverse the stoma.

If a large section of your large intestine is affected by diverticulitis and needs to be removed, or if you have multiple other conditions that make major surgery a risk, you may need a permanent ileostomy or colostomy.

Results of surgery

In general terms, elective (non-emergency) surgery is usually successful, although it does not achieve a complete cure in all cases. Following surgery, an estimated 1 in 12 people will have a recurrence of symptoms of diverticular disease and diverticulitis.

In an emergency setting, the success rate depends on how unwell you are when you require the operation.

Eating plenty of fibre can help prevent diverticular disease, and it can also ease your symptoms if you already have it.

Try to keep your diet balanced, with at least 5 portions of fruit and vegetables a day, along with whole grains. Adults should aim for about 18g (0.6oz) to 30g (1.05oz) of fibre a day, though the right amount depends on your height and weight. Your doctor can give you a target suited to you personally.

It is best to increase your fibre intake gradually, over a few weeks, rather than all at once. This helps you avoid problems like bloating and wind, which can come with a sudden jump in fibre. Drinking plenty of fluids alongside your fibre also helps keep these side effects away.

If you already have diverticular disease, your doctor may suggest avoiding nuts, corn and seeds, since there is a concern they could get lodged in the diverticular openings and trigger diverticulitis. Most people notice on their own if a particular food brings on symptoms. Probiotics are sometimes recommended too, though the evidence for them is thin. In truth, solid scientific evidence on preventing diverticular disease is still limited overall.

Good sources of fibre

Fibre is found in:

• fruit
• vegetables
• nuts
• breakfast cereals (check the label, as some have very little fibre)
• starchy foods such as brown bread, rice and pasta

Once you reach your fibre target, try to stay there for good.

Fresh fruit

• Avocado: a medium avocado gives about 4.9g of fibre
• Pear (with skin): a medium pear gives about 3.7g
• Orange: a medium orange gives about 2.7g
• Apple (with skin): a medium apple gives about 2g
• Raspberries: two handfuls (80g) give about 2g
• Banana: a medium banana gives about 1.7g
• Tomato juice: one small glass (200ml) gives about 1.2g

Dried fruit

• Apricots: 3 whole apricots give about 5g
• Prunes: 3 whole prunes give about 4.6g

Vegetables

• Baked beans in tomato sauce: half a can (200g) gives about 7.4g
• Red kidney beans, boiled: 3 tablespoons give about 5.4g
• Peas, boiled: 3 heaped tablespoons give about 3.6g
• French beans, boiled: 4 heaped tablespoons give about 3.3g
• Brussels sprouts, boiled: 8 sprouts give about 2.5g
• Potatoes, old and boiled: 1 medium potato gives about 2.4g
• Spring greens, boiled: 4 heaped tablespoons give about 2.1g
• Carrots, boiled and sliced: 3 heaped tablespoons give about 2g

Nuts

• Almonds: 20 almonds give about 2.4g
• Peanuts, plain: 1 tablespoon gives about 1.6g
• Mixed nuts: 1 tablespoon gives about 1.5g
• Brazil nuts: 10 nuts give about 1.4g

Breakfast cereals

• All Bran: a medium bowl gives about 9.8g
• Shredded Wheat: 2 pieces give about 4.3g
• Bran Flakes: a medium bowl gives about 3.9g
• Weetabix: 2 biscuits give about 3.6g
• Muesli, no added sugar: a medium bowl gives about 3.4g
• Porridge, made with milk or water: a medium bowl gives about 2.3g

Own brand versions of these cereals usually contain similar amounts of fibre.

Starchy foods

• Crispbread: 4 pieces give about 4.2g
• Wholemeal pitta bread: 1 piece (75g) gives about 3.9g
• Plain fresh cooked pasta: a medium portion (200g) gives about 3.8g
• Wholemeal bread: 2 slices give about 3.5g
• Naan bread: 1 piece gives about 3.2g
• Brown bread: 2 slices give about 2.5g
• Brown rice, boiled: a medium portion (200g) gives about 1.6g

Fibre supplements, usually powder sachets mixed with water, are also available from pharmacies and health stores, and some contain sweetener. A tablespoon of a typical supplement gives around 2.5g of fibre. If you need to take fibre supplements long term, your doctor can prescribe them for you.

Complications of diverticular disease and diverticulitis

Complications of diverticulitis affect 1 in 5 people with the condition. Those most at risk are aged under 50.

Bleeding

Around 15% of people with diverticular disease or diverticulitis experience bleeding, which is usually painless, quick and resolves itself in 70% to 80% of cases.

However, if the bleeding does not resolve itself, an emergency blood transfusion may be required due to excessive bleeding. If the bleeding is severe, you may need to be admitted to hospital for monitoring.

Urinary problems

Diverticulitis can lead to the inflamed part of the bowel being in contact with the bladder. This may cause urinary problems, such as:

• pain when urinating (dysuria)
• needing to urinate more often than usual
• in rare cases, air in the urine

Abscess

The most common complication of diverticulitis is an abscess outside the large intestine (colon). An abscess is a pus-filled cavity or lump in the tissue. Abscesses are usually treated with a technique known as percutaneous abscess drainage (PAD).

A radiologist (a specialist in the use of imaging equipment, such as computerised tomography (CT) scans) uses an ultrasound or CT scanner to locate the site of the abscess.

A fine needle connected to a small tube is passed through the skin of your abdomen (stomach) and into the abscess. The tube is then used to drain the pus from the abscess. A PAD is performed under a local anaesthetic.

Depending on the size of the abscess, the procedure may need repeating several times before all the pus has been drained. If the abscess is very small – usually less than 4cm (1.5 inches) – it may be possible to treat it using antibiotics.

Fistula

A fistula is another common complication of diverticulitis. Fistulas are abnormal tunnels that connect 2 parts of the body together, such as your intestine and your abdominal wall or bladder.

If infected tissues come into contact with each other, they can stick together. After the tissues have healed, a fistula may form. Fistulas can be potentially serious as they can allow bacteria in your large intestine to travel to other parts of your body, triggering infections, such as an infection of the bladder (cystitis).

Fistulas are usually treated with surgery to remove the section of the colon that contains the fistula.

Peritonitis

In rare cases, an infected diverticulum (pouch in your colon) can split, spreading the infection into the lining of your abdomen (perforation). An infection of the lining of the abdomen is known as peritonitis.

Peritonitis can be life-threatening, and requires immediate treatment with antibiotics. Surgery may also be required to drain any pus that has built up, and it may be necessary to perform a colostomy.

Intestinal obstruction

If the infection has badly scarred your large intestine, it may become partially or totally blocked. A totally blocked large intestine is a medical emergency because the tissue of your large intestine will start to decay and eventually split, leading to peritonitis.

A partially blocked large intestine is not as urgent, but treatment is still needed. If left untreated, it will affect your ability to digest food and cause you considerable pain.

Intestinal blockage from diverticular disease is very rare. Other causes, such as cancer, are more common. This is one of the reasons your GP will investigate your symptoms.

In some cases, the blocked part can be removed during surgery.

However, if the scarring and blockage is more extensive, a temporary or permanent colostomy may be needed.