A Wayside Inn of Ill Repute

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My anatomy teacher, Professor Max Hickey, had a wicked sense of humor. An anatomical out pocket on the bowel is called a diverticulum, which comes from the Latin meaning “a small diversion from the normal path”; however, Max taught us that it was Latin for “a wayside inn of ill repute”. I certainly like Max’s definition better, and his words have stayed with me for many years!

Inflammation of these anatomical out pockets is called Diverticulitis, and the little pockets are called ‘diverticulae’ (Latin plural of diverticulum). So, the condition of having diverticulae is called Diverticulosis, and if they become inflamed (from any reason) this is called Diverticulitis.

Diverticulae are more common in industrialized countries than in third world countries. The reason given for this is the lack of bulk present in the diet of industrialized countries allowing muscle contractions to create localized areas of high pressure allowing diverticulae to form, popping through the lining of the bowel.

The prevalence of diverticulae clearly increases with age. While fairly uncommon during the first four decades of life they reach a frequency of 50 percent in people older than 65. And welcome to the wonderful life of a retiree.

It must be remembered that Diverticulosis has no symptoms, but Diverticulitis does when they can rupture into the abdominal cavity, cause localized irritation and inflammation or produce an abscess. This is called acute diverticulitis.

Patients who have diverticulitis can present with a rather sudden onset of pain located in the lower left part of the abdomen over the sigmoid colon. It frequently is exquisitely tender and is associated with fever and a high white blood cell count.

Secondly, they can painlessly start to have significant amounts of rectal bleeding. When diverticulae bleed it is usually rather large amounts 500 ml or more. This happens without any inflammation whatsoever. The cause is a weakening of the blood vessel adjacent to the diverticulum.

Acute diverticulitis can be diagnosed by a typical history and a physical exam showing tenderness over the sigmoid colon which is located in the left lower part of the abdomen. If fever and a high white blood cell count are present this is confirmatory. A CAT scan or ultrasound of the lower abdomen can be very helpful in showing an inflammatory mass over the sigmoid colon.

Diverticular bleeding can be a bit more difficult to diagnose and is frequently a “diagnosis of exclusion”. Fortunately this is not common. Less than 5 percent of people with diverticular disease of the colon will bleed.

Acute diverticulitis is treated with antibiotics for 7-10 days. These antibiotics frequently have to be given intravenously. Diet is often severely limited during the first few days of treatment. Most patients will recover completely, but occasionally surgery is necessary in order to drain all the infected material and completely empty an abscess cavity. At times this can require the creation of a colostomy to remove the feces from the infected area. After this has healed (usually about 6 weeks) the colostomy is removed and the colon is restored to its original state with removal of the diseased portion of the colon.

Bleeding diverticulosis is managed initially by monitoring the patient closely regarding his rate of blood loss and giving blood transfusions if necessary. Fortunately the bleeding normally stops. If not, the part of the colon containing the bleeding diverticulum needs to be surgically removed.

There is much written but little proof that anything can be done to prevent a recurrence of bleeding diverticular disease of the colon or acute diverticulitis short of a surgical resection. Of those that have bled about 15 percent will have a second bleed. If a second bleed occurs, the risks increase to 50 percent they will have a third. About 25 percent of those patients with acute diverticulitis will have a relapse and many of these will need a surgical resection. The use of a high fiber diet or use of stool softeners has been advocated to prevent recurrences of this disease by some researchers. The theory is that bulk in the colon in the form of a high fiber diet will help prevent recurrences by preventing localize high pressures from occurring. I remain unconvinced.