Diverticulitis
Diverticular disease is one of the most common causes of abdominal pain in the Western world. In addition, it appears to be increasing in incidence and demonstrates an age-dependent distribution. For example, diverticulosis affects only 5 % of people age
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Diverticulitis Winston M. Chan and Amit Agarwal
Epidemiology Diverticular disease is one of the most common causes of abdominal pain in the Western world. In addition, it appears to be increasing in incidence and demonstrates an agedependent distribution. For example, diverticulosis affects only 5 % of people age 40, but can be found in two-thirds of adults by age 85 [1]. Approximately 20 % of patients with diverticulosis will suffer from at least one episode of diverticulitis. In fact, the prevalence of diverticulitis across all age groups in the USA is 60 per 100,000 [2]. Over a 7-year period from 1998 to 2005, Etzioni et al. demonstrated a 26 % increase in hospital admissions secondary to diverticulitis. In this study, the largest increase (82 %) was in the youngest cohort of patients age 18–44 [3]. The etiology for this increase is unknown, but may be related to dietary considerations. A gender predilection for diverticulitis has been demonstrated in some studies, but not duplicated in others [1, 4]. Obesity has been implicated but these findings have been inconsistent as well. In contrast, geographic patterns have been firmly established. While diverticular disease is predominately left sided (98.5 %) in Western societies, it is much more common on the right (70 %) in Asia [5].
Clinical Presentation Colonic diverticula are classified as “false” or pulsion diverticula since they do not contain all layers of the bowel wall. The colon is predisposed to develop diverticulosis at four well-described points secondary to a weakness of the bowel wall where the vasa recta penetrate the circular muscle layer
W.M. Chan • A. Agarwal (*) Department of Surgery, The University of Texas Health Science Center at Houston, 6550 Fannin Street, Suite 2307, Houston, TX 77030, USA e-mail: [email protected]
(Fig. 29.1) [6]. Although the vast majority of patients with diverticulosis will remain asymptomatic throughout their lives (70 %), others will suffer severe and sometimes repeated bouts of diverticulitis (20 %) and diverticular bleeding (10 %). Diverticulitis occurs when obstruction of the diverticulum by a fecolith causes localized perforation of the diverticulum and subsequent intra-abdominal infection. The patient with diverticulitis will commonly present with fever, leukocytosis, and left lower quadrant pain; however, the absence of these does not preclude a diagnosis of diverticulitis as about half of patients will not have a fever or leukocytosis [7]. The presence or absence of symptoms can be attributed to the severity of the underlying inflammatory process. Therefore, the diagnosis of diverticulitis is further characterized into uncomplicated and complicated to reflect the severity of the episode. With uncomplicated diverticulitis, there is colonic inflammation but without gross perforation (i.e., localized or diffuse pneumoperitoneum), phlegmon, abscess, obstruction, or fistula. Histologically, there is often micro-perforation of the colon. It accounts for the majority (75 %) of cases and is usually amenable to med
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