Diverticulitis/ Diverticulosis

Prevention of Diverticulitis

○ Adherence to a high-fiber diet ○ Decreased red meat intake ○ Adequate fluid and fiber intake to prevent constipation ○ Stop smoking ○ Exercise during periods of remission

Tx of Diverticulitis- MD or PA

○ Asymptomatic- does not require treatment ○ For uncomplicated diverticulitis, the primary treatment is bowel rest, antibiotics, and pain control ○ Surgery is currently performed laparoscopically on a case-by-case basis with good outcomes ○ Hospitalization is suggested for individuals with radiographic abnormalities, fever, and leukocytosis ○ Colonoscopy should be performed 4-6 weeks after resolution to verify the presence of disease and exclude colorectal cancer

Diverticulosis v. Diverticulitis

○ Diverticulosis: presence of the marble-sized pouches ○ Diverticulitis: infection or inflammation of the marble-sized pouches, causing abdominal pain, fever, nausea, and bowel habit changes

PT/OT for Diverticulitis

○ Exercise - establishing an exercise program ○ Physical activity can have a protective effect on the GI system ○ Vigorous physical activity lowers the risk of diverticulitis and diverticular bleeding ○ Individuals with diverticulitis have to be careful to avoid activities that increase intra-abdominal pressure to avoid further herniation and pain ○ Pain modulation and strengthening of the pelvic floor muscles is important for patients with diverticulitis ○ Back pain can occur as a symptom and should be treated

Symptoms

*Asymptomatic in 80% of affected people.* ○ If not inflamed, symptoms may be mild, nonspecific, and episodic pain. ○ Symptoms overlap with those of IBS, including bloating, cramping, irregular bowel movements, and flatulence. ● Episodic or constant abdominal pain is usually in the left quadrant or midabdominal region, and may extend into the back. Other symptoms: Fever, change in bowel habits, nausea, vomiting, and anorexia ● 10-15% will have urinary problems due to the close proximity of the bladder ● BM or Flatus may relieve symptoms

Stages of Diverticulitis

0: development I: asymptomatic II: symptomatic III: complicated

Segmental Colitis

Inflammation involving tissue surrounding the diverticulum but not inside the diverticulum itself, ○ Chronic abdominal pain associated with hematochezia (bleeding from the rectum) ○ Examination of tissue shows features similar to IBD and some affected people may be treated with drugs used in IBD therapy. (IBD=Inflammatory Bowel Disease)

Pathogenesis of Diverticulitis

Multifactorial process: related to diet, structural changes in the colonic wall, & functional changes in the bowels (intestinal mobility)

How is it cyclical?

○ causes scarring & narrowing of the bowel lumen, leading to obstruction ○ if this causes perforation, bacteria could be introduced, creating a vicious cyclical cycle that continuously occurs.

Could be secondary to fecal obstruction

○ increased pressure, ulcerations, bacterial overgrowth (similar to appendicitis) ○ fecal material or undigested food may collect, causing issues resulting in inflammation

Fiber theory

○ lack of it was originally thought to be the cause, producing small volume stools and decreased stool transit time ○ current studies provide conflicting results ○ more studies need to be done

Changes in intestinal motility/pressures

○ the colon contracts in segments rather than as a whole tube ○ the enteric nervous system play a role-imbalance between excitatory and inhibitory influences

Fistulas

○ the connection between the bowel and bladder comes together ○ supposed to be separate

Changes in muscular portion of the colonic wall

○ the longitudinal muscle (plicae circulares) becomes thickened from deposition of elastin - narrowing the lumen and increasing intraluminal pressure ○ the muscle cells themselves remain normal

What are Diverticula?

● Small bulging pouches that form in lining of the digestive system. ● They are most commonly found in the lower part of the large intestine, or the colon. -consist of mucosa and submucosa.

Morphology

● Taeniae coli becomes thickened from build-up of elastin ● Increased collagen production ● plicae circulares thickens, causing narrowing of the lumen and increasing intraluminal pressure--> can lead to ischemia ● colon does not move as a whole--moves in segments ● Ulcerations and perforations occur and allows for bacterial overgrowth ● Diverticular disease can lead to weakening of the blood vessels, increasing risk for bleeding (though bleeding is uncommon)

Etiology

● The cause is not conclusive! ● Some overall risk factors include: constipation, physical inactivity, obesity, smoking ● Connective tissue disorders play a role in increasing diverticula ● Affected by genetics, heredity, and lifestyle ● Steroid usage and immunosuppressants also can have an effect