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Diverticulosis[edit]

Diverticulosis  are outpocketings of the colonic mucosa and submucosa  and are  found most frequently in the left colon, especially in the sigmoid colon. This is uncommon before the age of 40, and increases in incidence after that age.  The diverticulae form  through weaknesses of muscle layers created by  the entry of blood vessels from the mesentery supporting the bowel.. The diverticula are of a pulsion type , that is a  pouch of mucus membrane projecting through the circular muscle layers to the pericolic fat and appendices epiploicae on the underside of the colon between the mesenteric and medial and lateral antimesenteric taeniae.

Diverticulosis is in general a benign condition but can become symptomatic or complicated. It is important to differentiate benign diverticulosis from diverticulitis 1 Signs and symptoms 2 Causes 3 Diagnosis 4 Management 6 Epidemiology 7 References 8 External links

Signs and symptoms[edit]

Most people with colonic diverticulosis are unaware of this structural change. When symptoms do appear in a person over 40 years of age then it is important to obtain medical advise and investigations to exclude more dangerous conditions eg cancer of the colon or rectum. [1] [2]

[3]

[4]

The clinical forms of colonic diverticulosis are

Symptomatic colonic diverticulosis[edit]

. This is the commonest complication of colonic diverticulosis. This is when the motility , that is the onward propulsive nature of contractions in the bowel become disorganised and even spasm can develop. This results in pain in the left lower abdomen and often is accompanied by the passage of small pelletty stools and slime which relieves the pain, Symptoms can consist of, 1.bloating, 2.changes in bowel movements (diarrhoea or constipation). 3.Non-specific chronic discomfort in the lower left abdomen, with occasional acute episodes of sharper pain. 4.abdominal pain, often after meals often in the left lower abdomen If these persist clinical investigation is advised.

Complicated colonic diverticulosis[edit]

. This is very uncommon but highly dangerous . The diverticulae may bleed either rapidly or slowly as a cause of anaemia. The diverticulae can become infected and develop abscesses or even perforate. These are serious complications and medical care is needed. Only infected diverticulae and development of abscesses merits the term diverticulitis. First time bleeding from the rectum, especially in individuals aged over age 40, could be due to colon cancer rather than diverticulosis. [5] [6] [7]

2. Aetiology[edit]

A diet without sufficient fiber makes the stools small, requiring the bowel to squeeze harder to move the smaller stool along the bowel.

Risk factors[edit]

1.increasing age 2.constipation 3.a diet that is low in dietary fiber content or high in fat 4. high intake of meat and red meat connective tissue disorders that may cause weakness in the colon wall (such as Marfan syndrome). The exact aetiology of colonic diverticulosis has yet to be fully clarified and many of the claims are only anecdotal [8] [9]. . The modern emphasis on the value of fibre in the diet began with Cleave [10] . A strong case was made by Neil Painter [11] and Adam Smith [12] that a deficiency of dietary fibre is the cause of diverticular disease. They argued that the colonic muscles needed to contract strongly in order to transmit and expel the small stool associated with a fibre deficient diet. The increased pressure within the segmented section of bowel over years gave rise to herniation at the vulnerable point where blood vessels enter the colonic wall. Denis Burkitt had suggested that the mechanical properties of the colon may be different in the African and the European subjects . Because Africans eat a diet containing much more fibre than Europeans they pass bulky stools, and hence rarely if ever develop colonic diverticulosis[13] , However changes in the strength of the colonic wall with age is an important aetiological factor 13. Eastwood MA (1998) Structure and function of the colon. In Encyclopedia of Human Nutrition, pp. 945-953 [MJ Sadler, JJ Strain and B Caballero, editors). San Diego, CA: Academic Press. </ref> . Connective tissue is a significant contributor to the strength of the colonic wall. The mechanical properties of connective tissue depend on a wide variety of factors, the type of tissue and its age, the nature of the intramolecular and intermolecular covalent cross links and the quantity of the glycosaminoglycans associated with the collagen fibrils. The submucosa of the colon is composed almost entirely of collagen, both type I and type III. Several layers of collagen fibres make up the submucosa of the human colon. The collagen fibril diameters and fibril counts are different between the left and right colon and change with age and in colonic diverticulosis[14], [15]. The implication being that changes which are normally associated with ageing are more pronounced in colonic diverticulosis[16]. Iwasaki found that the tensil strength of the Japanese colon obtained at postmortem declined with age. [17]. Similarly the mechanical properties of the colon are stronger in African than European subjects18 . The strength of the colon decreases with age in all parts of the colon, except the ascending colon. The fall in tensile strength with age is due to a decrease in the integrity of connective tissue[18] Cross linkage of collagen is increased in colonic diverticulosis </ref>. The mucosal layer is possibly more elastic and it is likely that the stiffer external layers break and allow the elastic mucosa to herniate through forming a diverticulum. Collagen has intermolecular and intramolecular cross links which stabilise and give strength to the tissue in which it is located. Accumulation of covalently linked sugar molecules and related increasing cross linking products are found in a variety of tissues with ageing, skin, vascular tissue, the cordae tendinae of heart valves and the colon.[19] This reduces the strength and pliability of the collagen.Colonic diverticulosis increases in frequency with age [20]. There is a reduction in the strength of the colonic mucosa with age, and that that increased contractions in the descending and sigmoid colon secondary to a insufficient fibre content of the diet cause protrusion through this weakened wall . Colonic diverticulosis is in general a benign condition of the bowel which uncommonly becomes symptomatic and even less commonly becomes a truly clinical complicated problem.

3. Diagnosis[edit]

Barium enema or colonoscopy are the most used test for diagnosis. This is important for treatment and investigation of other diseases. Other tests include abdominal X-ray, CT, or MRI. Note that if Diverticulitis (inflammation of the diverticula) is suspected, both colonoscopy and barium enema require extremely skilled hands .

4. Management[edit]

Many patients with diverticulosis have minimal or no symptoms, and do not require any specific treatment. A high-fiber diet and fiber supplements are advisable to prevent constipation .[21] [22]. The American Dietetic Association recommends 20-35 grams each day. Wheat bran has much to commend it as this has been shown to reduce intra colonic pressure [23] [24] Ispaghula is also effective at 1-2 grams a day. Colonic stimulants should be avoided. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says foods such as nuts, popcorn hulls, sunflower seeds, pumpkin seeds, caraway seeds, and sesame seeds have traditionally been labelled as problem foods for people with this condition. however, no scientific data exists to prove this hypothesis. The seeds in tomatoes, zucchini, cucumbers, strawberries, raspberries, and poppy seeds, are not considered harmful by the NIDDK. Treatments, like some colon cleansers, that cause hard stools, constipation, and straining, are not recommended. Some doctors also recommend avoidance of fried foods, nuts, corn, and seeds to prevent complications of diverticulosis. Whether these diet restrictions are beneficial is uncertain; Recent studies have stated that nuts and popcorn do not contribute positively or negatively to patients with diverticulosis or diverticular complications [25] [26] . When the spasm pain is troublesome the use of peppermint oil ( 1 drop in 50 ml water can be helpful or peppermint tablets eg colpermin. Complicated diverticulosis requires treatment of the complication. This is oftern called diverticulitis This necessitates skilled medical care of the infection , bleeding and perforation which may include intensive antibiotic treatment, intravenous fluids and surgery. Complications are more common in patients who are taking NSAIDS or aspirin . As diverticulosis occurs in an older population such complications are serious events.

5. Epidemiology[edit]

About 10% of the US population over the age of 40 and half over the age of 60 has diverticulosis. This disease is common in the US, Britain, Australia, Canada, and is uncommon in Asia and Africa [27] [28]. Large-mouth diverticula are associated with sclerodema

7. References[edit]

  1. ^ 1. Shepherd NA (1992) Diverticular disease. In Oxford Textbook of Pathology, pp. 1256-1258 [J O'D McGee, PG Isaacson and NA Wright, editors]. Oxford: Oxford University Press.
  2. ^ 2. Christensen J (1991) Gross and microscopic anatomy of the large intestine. In The Large Intestine Physiology, Pathophysiology and Disease, pp. 13-35 [SF Phillips, JH Pemberton and RG Shorter, editors]. New York: Raven Press.
  3. ^ 3. West AB 2008 The pathology of diverticulitis. J Clin Gastroenterol. 42:1137-8.
  4. ^ 4. Drummond H (1917) Sacculi of the large intestine with special reference to their relation to the blood vessels of the bowel wall. British Journal of Surgery 4,407.
  5. ^ 5. Eastwood MA (1987) Diverticular disease. In Oxford Textbook of Medicine, 2nd ed., pp. 12.133-12.137 [DJ Weatherall, JGG Ledingham and DA Warrell, editors). Oxford: Oxford University Press.
  6. ^ 6. Stollman N, Raskin JB. 2004 Diverticular disease of the colon. Lancet. ;363 :631-9.
  7. ^ 7. Touzios JG, Dozois EJ 2009 Diverticulosis and acute diverticulitis. Gastroenterol Clin North Am.;38:513-25.
  8. ^ 8. Commane DM, Arasaradnam RP, Mills S, Mathers JC, Bradburn M. 2009 . Diet, ageing and genetic factors in the pathogenesis of diverticular disease. World J Gastroenterol. ;15 :2479-88.
  9. ^ 9. Raskin M 2008 History, incidence, and epidemiology of diverticulosis.J Clin Gastroenterol. ;42:1125-7
  10. ^ 10. Cleave TL 1974 The Saccharine disease Wright Bristol
  11. ^ 11. Painter NS (1975) Diverticular disease of the colon. Heinemann Medical Books
  12. ^ 11a Smith AN (1991) Diverticular disease of the colon in The Large Intestine ed Philllips SF, Pemberton JH and Shorter RG Raven Press pp549-578
  13. ^ 12. Burkitt DP & Trowell HC, editors (1975) Refined Carbohydrate Foods and Disease. Some Implications of Dietary Fibre. London: Academic Press.
  14. ^ 14. Thomson HG, Busuttil A, Eastwood MA, Smith AN & Elton RA (1987) Submucosal collagen changes in the normal colon and in diverticular disease. International Journal of Colorectal Disease 20,208-213.
  15. ^ 15. Parry DAD, Bames GRG & Craig AS (1978) A comparison of the size distribution of collagen fibrils in connective tissues as a function of age and a possible relation between fibril size distribution and mechanical properties. Proceedings of the Royal Society of London 203B, 305-321.
  16. ^ 16. Flint MH, Craig AS, Riley HC, Gillard GC & Parry DAD (1984) Collagen fibril diameters and glycosaminoglycan content of skins - indices of tissue maturity and function. Connective Tissue Research 13, 69-81.
  17. ^ Iwasaki, cited by Yamade, M.A.B.A . Strength of biological materials; Baltimore, Williams and Watkins, 1970).
  18. ^ . 18. Watter, D.A.K., Smith A.N., Eastwood M.A., Anderson K.C., Elton R.A. and Mugerwa, J.W.; 1985: Mechanical properties of the colon: comparison of the features of the African and European colon in vitro. Gut 26, 384-392).
  19. ^ 19. Wess L, Eastwood MA, Wess TJ, Busuttil A and Miller A ( 1995) Cross linkage of collagen is increased in colonic diverticulosis Gut 37 , 91-94.
  20. ^ 20.Eastwood M Colonic diverticula in Proceedings of the Nutrition Society 2003 Symposium on Dietary fibre in Health and disease . General Aspects of dietary fibre”. Vol 62 ; 1-249
  21. ^ 21. Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC (1994). "A prospective study of diet and the risk of symptomatic diverticular disease in men" . Am. J Clin. Nutr. 60 (5): 757-f14. PMID 7942584. http://www.ajcn.orgicgilreprint!60/5/757..
  22. ^ 22. Gear JS, Ware A, Fursdon P, et al. (1979). "Symptomless diverticular disease and intake of dietary fibre". Lancetl (8115): 511-4. doi: 10. 10 1 6/S0 140-6736(79)90942-5. PMID 85104. http://1inkinghub.elsevier . com/retrieve/pii/SO 140-673 6(79)90942-5.
  23. ^ 23. Marlett JA, McBurney MI, Slavin JL (2002). "Position of the American Dietetic Association: health implications of dietary fiber". JAm Diet Assoc 102 (7): 993-1000. doi:l0.1016/S0002- 8223(02)90228-2. PMID 12146567. http://www.eatright.org/cps/rde/xchglada/hs.xslladvocacy_adar2 _ 0702 _END _ HTMLhtm..
  24. ^ 24. Eglash A, Lane CH, Schneider DM (2006). "Clinical inquiries. What is the most beneficial diet for patients with diverticulosis?". The Journal of family practice 55 (9): 813-5. PMID 16948968.
  25. ^ 25. Strate LL; Liu YL; Syngal S; Aldoori WH; Giovannucci EL (2008). "Nut, Corn, and Popcorn Consumption and the Incidence of Diverticular Disease.". JAMA. 300 (8): 907-914
  26. ^ 26. Eating Nuts, Popcorn Not Linked With Higher Risk of Diverticulosis Newswise, Retrieved on August 26,2008
  27. ^ 27. Manousos 0, Day NE, Tzonou A, et al. (1985). "Diet and other factors in the aetiology of diverticulosis: an epidemiological study in Greece". Gut 26 (6): 544-9. doi: 1 0.1136/gut.26.6.544. PMID 3924745. PMC 1432747. http://gut.bmj.com/cgi/reprint!26/6/544.
  28. ^ 28. Comparato G, Pilotto A, Franze A, Franceschi M, Di Mario F (2007). "Diverticular disease in the elderly". Digestive diseases (Basel, Switzerland) 25 (2): 151-9. doi:l0.11591000099480
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