Diverticulitis (diverticulosis, Diverticular disease) is a general term that refers to the presence of diverticula, small pouches in the colonic (large intestinal) wall. These outpouchings arise when the inner layers of the colon push through weaknesses in the outer muscular layers. Diverticulitis arises when diverticula become inflamed or infected.
Thank you for reading this post, don't forget to subscribe!Notably, diverticulosis can occur anywhere in the colon, but it is most common in the descending or sigmoid colon (left colon).
The cause of diverticulosis is unclear, but it has been associated with increased pressure from constipation or increasing abdominal girth in obesity. The classic high-fat, artificial, nonorganic and low-fiber diet may be a major contributor to the development of diverticulosis. The low-fiber diet is thought to predispose to diverticulosis owing to a slower fecal transit time and smaller stool weight.
Diverticular disease can be asymptomatic (diverticulosis) or involve acute or chronic, symptomatic inflammation of these pouches (diverticulitis). Although diverticulitis has been generally considered a disease of older adults, as many as 20% of patients with diverticulitis are younger than 50 years. In its chronic form, patients may have recurrent bouts of low-grade or overt diverticulitis.
Signs and symptoms of diverticulitis
The clinical presentation of diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence of complications. The usual initial symptoms are as follows:
- Abdominal pain (most commonly in the left lower quadrant)
- Nausea and/or vomiting
- Constipation or obstipation
- Flatulence.
- Bloating.
- Fever.
On physical examination:
Localized abdominal tenderness. Abdominal distention. Tympanic abdomen to percussion. A tender mass (abscess formation). Hypo- or hyperactive bowel sounds or absent bowel sounds if there is perforation. Generalized abdominal pain with rebound and guarding (perforation).
Urinary tract findings (Colo vesicular/Colo vaginal fistula) include suprapubic, flank, costovertebral tenderness; pneumaturia (air in urine); fecal Uria (stool in urine); purulent vaginal discharge.
Staging
Clinical staging by Hinchey’s classification is based on computed tomography findings and directed toward selection of the proper surgical procedure when diverticulitis is complicated, as follows:
- Stage I disease: Phlegmon or localized pericolic or mesenteric abscess.
- Stage II disease: Walled-off pelvic, intra-abdominal, or retroperitoneal abscess.
- Stage III disease: Perforated diverticulitis causing generalized purulent peritonitis.
- Stage IV disease: Rupture of diverticula into the peritoneal cavity, with fecal contamination causing generalized fecal peritonitis
Table. Modified Hinchey Classification Stage and Diverticulitis Category
| Modified Hinchey Classification Stage | Category | |
| 0 | Clinically mild diverticulitis, or diverticula with colonic wall thickening on CT | Uncomplicated |
| Ia | Colonic reaction with inflammatory reaction in the pericolic fat (phlegmon) | Uncomplicated |
| Ib | Pericolic or mesenteric abscess | Complicated |
| II | Intra-abdominal abscess, pelvic or retroperitoneal abscess | Complicated |
| III | Generalized purulent peritonitis | Complicated |
| IV | Generalized fecal peritonitis | Complicated |
Diagnosis of diverticulitis
The diagnosis of acute diverticulitis can usually be made on the basis of the history and physical examination findings, laboratory tests are helpful when the diagnosis is in question, for example:
- WBC or the white blood cell count (show leukocytosis and a left shift, but it may be normal in immunocompromised, elderly, or less severely ill patients).
- A hemoglobin level is important in patients who report hematochezia.
- Electrolyte assays (may be helpful in case of vomiting or has diarrhea).
- Assess renal function prior to the administration of most intravenous contrast material.
- Liver enzyme and lipase levels may help to exclude other causes of abdominal pain.
Urinalysis may reveal red or white blood cells in patients with a Colo vesicular fistula or with diverticulitis adjacent to the ureters or the bladder.
Obtain blood cultures prior to the administration of empiric parenteral antimicrobial therapy in patients who are severely ill or in those with complicated disease.
A urine culture may distinguish sterile pyuria due to inflammation from polymicrobial infection due to a fistula.
Computed tomography (CT) scanning of the abdomen is considered the best imaging method to confirm the diagnosis. Sensitivity and specificity, especially with helical CT and colonic contrast medium, can be as high as 97%. Possible CT scan findings include the following:
- Pericolic fat stranding due to inflammation.
- Colonic diverticula.
- Bowel wall thickening.
- Soft-tissue inflammatory masses.
- Phlegmon.
- Abscesses.
Other tests and procedures are as follows:
Contrast enema, using water-soluble medium, may be an option in mild-to-moderate uncomplicated cases of diverticulitis. A plain abdominal radiographic series with supine and upright films can demonstrate bowel obstruction or ileus; the presence of free air can indicate bowel perforation.
Allopathic treatment of diverticulitis
The management of patients with diverticulitis depends on their presentation severity, presence of complications, and comorbid conditions.
Uncomplicated diverticulitis can be managed medically and in an ambulatory setting. Complicated disease requires a more aggressive approach that can often require urgent or elective surgery, and treatments that are specific to the complication itself (i.e. abscess drainage).
The modified Hinchey classification is based on CT scan findings and is used to categorize diverticulitis, as well as help to guide appropriate interventions.
Antibiotics have been the mainstay of allopathic therapy for most patients with acute diverticulitis, but more recently, their necessity has been questioned, especially in mild, uncomplicated disease.
Outpatient treatment of diverticulitis
Patients with clinically mild diverticulitis, typically with Hinchey stage 0 and Ia disease, are considered uncomplicated and can be treated with the following outpatient regimen:
Clear liquid diet for 2-3 days; advancement to low fiber as tolerated. 7-10 days of oral (PO) broad-spectrum antimicrobial therapy on a case-by case basis. Acetaminophen and antispasmodics for pain.
The effectiveness of single or multiple-agent antibiotic regimens for outpatient therapy are essentially the same when they provide both anaerobic and aerobic coverage.
Potential regimens include the following:
Ciprofloxacin plus metronidazole. Trimethoprim-sulfamethoxazole plus metronidazole. Amoxicillin-clavulanate. Moxifloxacin (for patients’ intolerant of both metronidazole and beta-lactam agents).
Indications for hospital admission include the following:
- Evidence of severe diverticulitis (i.e. systemic signs of infection or peritonitis).
- Inability to tolerate oral hydration.
- Failure of outpatient therapy (i.e. persistent or increasing fever, pain, or leukocytosis after 2-3 days).
- Immune-compromise or significant comorbidities.
- Pain severe enough to require parenteral narcotic analgesia.
Inpatient treatment of diverticulitis
Patients with complicated diverticular disease fall under Modified Hinchey stage Ib II, III and IV. Individuals in Modified Hinchey stage Ib may require hospitalization and the following treatment regimen:
- Clear liquid diet; advancement to low fiber as tolerated.
- Intravenous (IV) or PO antibiotics.
- Elective surgical resection.
- Abscess >4 cm: Drain percutaneously.
- Abscess < 3 cm: Antibiotics.
Modified Hinchey stages II-IV require hospitalization, nothing by mouth, IV antibiotics, and 
percutaneous abscess drainage; surgical consultation and elective procedure for patients in stage II, and urgent surgical evaluation and resection for those in stage III and IV.
Monotherapy with beta-lactamase-inhibiting antibiotics or carbapenems is appropriate for patients who are moderately ill and require admission. Such antibiotics include piperacillin/tazobactam, ticarcillin/clavulanic acid, or ertapenem
Monotherapy in severely ill patients, especially those who are immunocompromised includes meropenem, imipenem-cilastatin, piperacillin-tazobactam, or doripenem.
Multiple-drug regimens may consist of metronidazole and a third-generation cephalosporin or a fluoroquinolone, such as ceftriaxone, cefotaxime, ciprofloxacin, or levofloxacin. Multiple-drug regimens include cefepime plus metronidazole, as well as ceftazime plus metronidazole.
Pain management considerations are as follows:
- Morphine is preferred, despite theoretical risk of affecting bowel tone and sphincters.
- Meperidine is associated with adverse effects.
Nonsteroidal anti-inflammatory drugs and corticosteroids have been associated with a greater risk of colonic perforation.
Acetaminophen and antispasmodics such as dicyclomine are first-line agents for managing pain and cramping in mild to moderate disease.
Classic surgical indications include some features characteristic of Hinchey stage III or IV disease, such as the following:
- Free-air perforation with fecal peritonitis.
- Suppurative peritonitis secondary to a ruptured abscess.
- Uncontrolled sepsis.
- Abdominal or pelvic abscess (unless CT scan-guided aspiration is possible).
- Fistula formation.
- Intestinal obstruction.
- Failing medical therapy
- Immunocompromised status.
Homeopathic treatment for diverticulosis
Colocynthis
Agonizing cutting pain in abdomen causing patient to end over double, and pressing on the abdomen. Pain in small spot below navel, worse, gentle touch. Contraction of the muscles. Dysenteric stool. Jelly-like stools. Musty odor. Distention. Colic. Peritonitis. Tumors. Acts like a broad-spectrum antibiotic.
Heper Sulphuricum
Abscess. Constipation. Diaphragmitis. Hemorrhoids. Shooting abdominal pains. Rectal hemorrhages. Hepatitis, hepatic abscess; abdomen distended, tense; chronic abdominal affections. Stool clay-colored and soft. Sour, white, undigested, fetid. Loss of power to expel even a soft stool.
Bryonia Alba
Nausea and faintness. Vomiting of bile and water immediately after eating. Abdomen sensitive to touch, sensitiveness of epigastrium to touch. Liver region swollen, sore, tensive. Burning, incisive or stitching pain, stitches; worse, pressure, coughing, breathing. Tenderness of abdominal walls. Constipation; stools hard, dry, as if burnt; seem too large. Stools brown, thick, bloody. Hard swelling round the navel.
Hydrastis Canadensis
Acts especially on mucous membranes, relaxing them and producing a thick, yellowish, ropy secretion, weak muscular power. Weak digestion. Bitter taste. Pulsation in epigastrium. Atonic dyspepsia. Ulcers and cancer. Gastritis. Gastro-duodenal catarrh. Liver torpid, tender. Jaundice. Gallstones. Dull dragging in right groin with cutting sensation into right testicle.
Back – Dull, heavy, dragging pain and stiffness, particularly across lumbar region, must use arms in raising himself from seat. Rectal prolapses, anus fissured. Constipation. During stool, smarting pain in rectum, after stool, long-lasting pain. Hemorrhoids; even a light flow exhaust. Contraction and spasm.
Arnica Montana
Abscess. Apoplexy. Back pains. Suppuration. Bloody vomiting. Shooting pain in splenic, umbilical region and/or liver region. Strangulation. Stool with mucus. Tympanites.
Aloe Socotrina 
Tension, stitching pain in the region of the liver. Uneasiness, flashes, pulsation, rumbling, heat, pressure in liver region. Congestion to the abdomen. Sensation of fulness, heaviness, heat and inflammation. The whole abdomen is painfully sensitive to the touch. Bloated abdomen, more on the left side, or along the colon, worse after eating. Distension of the abdomen with flatus moving about. Discharge of much flatulency, burning, smelling offensive, relieving the pain in the abdomen. Much soreness and cutting pains in the whole abdominal cavity, so that a false step hurt clear to the pit of the stomach. Heaviness, fulness, and pressing down in the pelvis.
Sudden or continued urging to stool. The hard stool falls without being noticed. Involuntary soft stool, while passing wind, with the diarrhea, flatulency, pinching in the abdomen, pain in the back and rectum, and chilliness. Stools like mush; thin, bright, yellow, grey, hot, undigested. Frequent stools of bloody water: violent tenesmus; fainting; passing of mucus in jelly-like lumps, much flatus. Itching, burning, pulsations, pain as from fissures, at the anus. Hemorrhoidal tumors, protrude like bunches of grapes, very painful, sore, tender, hot, relieved by cold water.
Megnesia Phosphoricum
Constant nausea. Bilious vomiting, at times streaked with blood. Cancer of stomach; intolerable burning pain; vomiting; hiccough. Intense cutting, shooting, cramping pains in region of stomach and epigastrium, on border of lower ribs. Sudden diarrhea; stools frequent; at first thick, dark brown, mushy; then lighter; almost white and watery; finally mixed with blood.
Gelsemium
Thirst. Increased appetite, easily satisfied with small quantities of food. Nausea with giddiness and headache. Gnawing pain in the transverse colon. Sudden spasmodic pains in upper part of abdomen, sensation of contraction and soreness in abdominal walls. Tenderness in iliac region. Typhus. Rumbling in abdomen with discharge of wind above and below. Periodic colic with diarrhea with yellow discharges. The soft stool is passed with difficulty as if the sphincter ani resisted the passage by contraction. Paralysis of the sphincter ani, with disposition to prolapsus ani. Stools loose, dark yellow, bilious; cream-colored; clay-colored; green. Diarrhea with intermittent fever.
Arsenicum Album
Nausea, retching, vomiting, after eating or drinking. Anxiety in pit of stomach. Long-lasting eructation. Vomiting of blood, bile, green mucus, or brown-black mixed with blood. Stomach extremely irritable. Liver and spleen enlarged and painful. Ascites and anasarca. Abdomen swollen and painful. Pain as from a wound in abdomen on coughing.
Painful, spasmodic protrusion of rectum. Tenesmus. Burning pain and pressure in rectum and anus. Stool small, offensive, dark, with much prostration. Body cold as ice. Hemorrhoids burn like fire; relieved by heat.
China officianalis
Tender, cold. Vomiting of undigested food. Slow digestion. Flatulent colic; better bending double. Tympanitic abdomen. Pain in right hypochondrium. Gall-stone colic. Liver and spleen swollen and enlarged. Jaundice. Internal coldness of stomach and abdomen. Gastro-duodenal catarrh. Stool – undigested, frothy, yellow; painless, difficult even when soft.
Rhus Toxicodendron 
Unquenchable thirst. Bitter taste. Nausea, vertigo, and bloated abdomen after eating. Violent pains, relieved by lying on abdomen. Swelling of inguinal glands. Pain in region of ascending colon. Colic, compelling to walk bent. Rumbling of flatus on first rising, but disappears with continued motion. Bloody diarrhea of blood with slime and reddish mucus, with tearing pains down thighs. Frothy, painless stools.
Prognosis
The prognosis in patients with diverticulitis depends on the severity of the illness, the presence of complications, the presence of any coexisting medical problems and most important type of treatment.
Younger patients with diverticulitis may have more severe disease, possibly due to a delay in the diagnosis and treatment. Immunosuppressed patients have significantly higher morbidity and mortality due to sigmoid diverticulitis.
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Dr. Sayyad Qaisar Ahmed (MD {Ukraine}, DHMS), Abdominal Surgeries, Oncological surgeries, Gastroenterologist, Specialist Homeopathic Medicines.
Senior research officer at Dnepropetrovsk state medical academy Ukraine.
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