Diverting the ticuli, but to where?

What is a ticuli? Where are they going? Why are they being diverted? What the hell is John talking about? All fantastic questions but alas, you shall not have answers to any of those. Instead, you will read about diverticulitis. Ahhhh, now the title makes sense. You can tell me I am a genius later, for now, let's learn a bit. 

Diverticulitis is an inflammation (-itis) of the diverticulum in the colon. The diverticulum are little pouches that come off the colon and typically extend into the muscle but remain intact. Think of it as putting an exam glove on and putting your finger in water, your finger is the in the water but the barrier is still there to prevent the water from getting in. The colon out-pouches but the contents do not spill into the muscle or abdomen (hopefully). These diverticulum can be chronic and when multiple are present but not inflamed, it is called diverticulosis. -itis versus -osis, inflamed versus not. Like any sort of rough surface, things can get stuck in those pouches and that can be irritating. 

I honestly thought that eating nuts and all that made diverticulitis worse, but that does not seem to be the case. Regardless, when irritated, it starts to hurt. Diverticulosis is asymptomatic until that point. Inflammation can lead to infection, pain, perforation, and more. It is generally thought that diverticulitis is primarily caused be fecal obstruction of the diverticulum which allows bacteria to grow. If left unchecked, as in a person with a compromised immune system, this can form abscesses, fistulae, peritonitis, and sepsis depending how much from the colon gets into the abdomen. This is similar to what can happen in any number of blocked passageways. Gallbladder or ureteral obstruction, ischemia of a limb/finger/toe, bowel obstruction, or clogged sewer line. You've got the buildup of pressure and of bacteria.  

Studies show between a 10-25% risk of developing diverticulosis throughout one's life, with an estimated 50% of Americans above 60 having diverticulosis. For those who progress to diverticulitis, the incidence of recurrence increases with each flare. There have been a variety of chronic issues that have been studied in relation to diverticulitis. I image the bad mood I'm in when I have abdominal pain from eating too fast, chronic abdominal pain? I'd be cranky. IBS was 5 fold more common, and mood disorders twice as common in veterans with diverticulitis. Chronic inflammation can also cause a range of side effects, the treatment with antibiotics for diverticulitis can cause diarrhea and nausea. The same antibiotics can place the individual at risk for C. diff, the development of resistance, out of whack microbiome, fungal infections, and just feeling like crap. Not to mention the financial strain which is not insignificant. 

Risks abound in modern life, with a big theory positing that our low fiber diets have contributed. It, low fiber not the clown, has been linked an increased risk for colorectal cancer, and cancer is often related to inflammation. Does diverticulitis or -losis increase the risk of colorectal cancer? Yes in deed it does, though it seems more so after acute exacerbations.  So it is like some inception of fiber and stool and intestines. Sounds like a terrible story, but alas, cest la vie. 

I mentioned antibiotics before and should stipulate that most cases of diverticulitis are uncomplicated (~88%) and do not necessitate the use of antibiotics. Around 5% of uncomplicated cases will become complicated over time, usually in those with comorbidities which I will talk on later. For those cases of complicated diverticulitis (~12%), i.e. those with abscesses or perforations, they have a greater role. The cormorbidities could be anything from major issues such as colon cancer (or most cancers), HIV or other immuno-compromising conditions or medications (tacrolimus, cyclosporine), uncontrolled diabetes, you get the idea. In those with signs of sepsis, WBC above 15, CRP above 140, or vomiting, bloody stools and the like, wider antibiotic coverage is needed. 

From the American Gastroenterological Association and the Agency for Healthcare Research and Quality we get the following guidelines. The therapy should cover common diverticulitis causing bugs, those being B. fragilis, K. pneumoniaem or E. coli with local patters of resistance taken into account. Amoxicillin/clavulanic acid, a cephalosporin, along with metronidazole is the first choice, given the E. coli is not resistant to the amox/clav. Complicated diverticulitis with sepsis suspected should include piperacillin/tazobactam or cefepime. If there is a true allergy to penicillins then a fluoroquinolone plus metronidazole or moxifloxacin are the drugs of choice, adding vancomycin in septic patients. For pain, NSAIDs should be avoided as they can increase the risk of perforation, 1 point for acetaminophen. 

As with any infection, in a perfect world all the abscesses would be drained as here, if possible that is an important part of treatment. If there is an area the antibiotics don't reach then complications can occur even after treatment has ended. speaking of after treatment, how should we live our lives post-diverticulitis? Getcha some fiber in your diet. Bulking your stools up allows the intestines to more easily push it out, using less pressure. Other modifiable issues include smoking, overweight or obesity, chronic NSAID use, and constipation (which could be modifiable, depends on the cause). 

References 

AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review from Gastroenterology 2021 by Peery et al.

Agency for Healthcare Research and Quality: Best Practiced in the Diagnosis and Treatment of Diverticulitis and Biliary Tract Infections in the Reducing Hospital Acquired Infections section, published November 2019

Association between diverticular disease and colorectal cancer: a bidirectional mendelian randomization study by Zhang et al., in BMC Cancer 2023

Cancer risk in patients with diverticular disease: A nationwide cohort study by Ma et al., in the Journal of the National Cancer Institute 2023

Diverticular disease: A therapeutic overview by Antonio Tursi from the World Journal of Gastrointestinal Pharmacology ad Therapeutics 2010

Dietary fiber intake and risk of colorectal cancer and incident and recurrent adenoma in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial by Kunzmann et al., in the American Journal of Clinical Nutrition 2015

Diverticulitis from the NIH: National Library of Medicine

Epidemiology, Pathophysiology, and Treatment of Diverticulitis by Strate & Morris in Gastroenterology 2019

Image of a gross specimen with diverticulitis from Wikipedia

Risk of colorectal cancer in patients with diverticular disease by Meyer et al., in the World Journal of Clinical Oncology 2018