Diverticular Disease

Diverticular Disease
Diverticular Disease
By Dr. Tan Wah Siew
Diverticuli are sac-like pouches of the inner lining of the colonic wall (mucosa and submucosa) that protrude through the muscular layer of the colon.
The incidence of diverticular disease increases with age. Diverticulosis is unusual in individuals under 40 years of age, but, depending on the country, may be present in more than 50% of individuals more than 80 years old. Industrialisation and development of a country is also associated with a higher incidence of diverticular disease in the population.

What causes the development of diverticular disease?

The exact cause is not entirely known and is likely a combination of factors including

  • A diet low in fibre (especially insoluble fibre) and high in red meat
  • Disordered intestinal motility
  • Abnormalities in the colonic wall structure
  • Inflammation
  • Colonic microbiota
  • Obesity
  • Genetic predisposition

It is believed that these factors lead to an increase in pressure within the lumen of the digestive tract, resulting in the formation of diverticuli.

What are the symptoms of diverticular disease?

  • Asymptomatic

    Most patients (75-90%) with diverticular disease are completely asymptomatic.
  • Diverticulitis

    This refers to inflammation/infection of the diverticuli, and is the most common complication of diverticular disease. Symptoms include abdominal pain, fever, nausea and change in bowel habits.

    Severe diverticulitis can lead to colonic perforation, formation of fisulae (abnormal communication) between the colon and other organs and intra-abdominal abscess formation. This can be associated with severe abdominal pain, spiking fever and uncontrolled sepsis.
  • Diverticular bleeding

    Bleeding from diverticular disease may occur in 3 to 15% of individuals. Patients typically present with painless but large amount of blood in the stools. Diverticular bleeding is the most common cause of brisk lower gastrointestinal bleeding.
  • Symptomatic uncomplicated diverticular disease (SUDD)

    Symptoms of SUDD include persistent or recurrent abdominal pain, bloating or changes in bowel habit in the absence of overt inflammation.


As most people do not have symptoms, diverticular disease is often found incidentally during a colonoscopy or CT scan.

10-25% of patients may have symptoms including bleeding, infection, and abdominal pain. Approximately 5% of patients may eventually develop complications such as perforation, obstruction, severe life threatening haemorrhage, fistulae, or abscesses.

Perforation, obstruction, abscesses and fistulae are diagnosed with a CT scan of the abdomen or pelvis. Bleeding diverticular disease may be diagnosed with colonoscopy, or with a CT mesenteric angiogram.

These complications may necessitate surgery to remove part of or the entire colon. Surgery can be performed with minimally invasive techniques.


  • Asymptomatic

    Asymptomatic diverticular disease does not require any treatment.
  • Diverticulitis

    Treatment of uncomplicated diverticulitis is with antibiotics and bowel rest. The majority of patients recover uneventfully, although recurrent diverticulitis can occur in 20-35% of patients presenting with the first attack of acute diverticulitis.

    Patients with diverticulitis not responding to antibiotics, or with colonic perforation or intra-abdominal abscess, will require surgery. Surgery usually entails removal of the segment of bowel involved by diverticulitis. A stoma is sometimes required, particularly if there is a large amount of pus or faecal spillage from bowel perforation.
  • Diverticular bleeding

    Most episodes of diverticular bleeding stop spontaneously, although admission to hospital and blood product transfusions may be required.

    Patients with massive bleeding requiring multiple bags of blood product transfusions may require emergency surgery to remove the colon in order to stop the bleeding. A total colectomy (removal of the entire colon) is frequently required.
  • Symptomatic uncomplicated diverticular disease (SUDD)

    Patients with SUDD can be treated with a combination of fibre supplementation, probiotics, antibiotics like rifaximin and/or anti-inflammatory agents like mesalamine.