The dietary treatment for diverticulitis flare ups has taken an about-face in recent years. In the past, people were advised to adhere to bland and low-residue diets. These are exactly the diets which, it seems, were responsible for causing the diverticulosis in the first place. Nowadays, people are encouraged to consume diets that are higher in fiber and roughage. The fiber increases the quantity of stool and softens its consistency. Commercial preparations, such as Metamucil, also have a similar effect.

Although fiber may not be of benefit to all people, it does seem that a high fiber diet lessens the frequency of the problems that may result from diverticulosis. It is hoped that high fiber diets, when eaten at younger ages, may even help to prevent diverticulosis from occurring at all.

The key to the use of fiber is to use it in moderation. As many people already have discovered, fiber, found in cereals, fibers, and vegetables, can itself cause a sense of bloating and cramps. People should eat a quantity of fiber that does not cause these problems, yet is sufficient for softening the stools. This can only happen with trial and error, and anywhere from three to eight weeks must be allowed to see if fiber has an effect.

It is hoped that as people become much more aware of the importance of dietary fiber, then diverticulosis, a disease of modern society, may become a thing of the past.

Diverticulitis is often incorrectly diagnosed on presentation and computed tomography (CT) scanning is probably the best tool for correcting this situation. That’s the conclusion of a retrospective analysis of 125 acute diverticulitis cases undertaken by researchers at the University of Alberta, Edmonton. The cases were seen between mid - 2005 and early 2007.

The study was undertaken in part to assess compliance with treatment guidelines for complicated and uncomplicated diverticulitis endorsed by the Canadian Society of Colon and Rectal Surgeons. Results were presented here at the annual meeting of the Royal College of Physicians and Surgeons by Dr. David Williams, a general surgery resident at the university.

Guidelines recommend complicated potential diverticulitis surgery cases with free perforation or fistula be treated surgically. Percutaneous drainage is recommended if an abscess is found. Conservative management is advocated for uncomplicated cases with antibiotics and bowel rest recommended.

In their analysis, the researchers assessed how valuable clinical markers such as fever, pain and white blood cell count were in making a correct diagnosis. A similar assessment of ultrasound, CT and contrast enema studies was undertaken.

We wanted to see how we were treating our patients and if it was treatment according to the guidelines,” Dr. Williams said in an interview. Ten patients were excluded from the outcome analysis, he said, because although they were diagnosed with diverticulitis on admission they were later found to have a different problem.

The researchers found only 60% of patients had the correct diagnosis made at presentation. The sensitivity and specificity of CT was better than any of the other tests. Patient - reported pain was a reliable marker of a diverticulitis diet candidate but had no specificity.

Perforated sigmoid diverticulitis and their abscesses often resolve spontaneously. However, large or unresolving abscesses may require percutaneous drainage under ultrasound or CT guidance. Perforation of a diverticular abscess into the peritoneal cavity will result in purulent peritonitis with localized tenderness becoming generalised peritonism.

The localized inflammatory process associated with a diverticulum may perforate through another epithelial surface to form a fistula. The commonest type of fistula associated with diverticular disease is a colovesical fistula resulting from perforation of a diverticulum into the bladder. Patients with colovesical fistulae may present without bowel symptoms but with recurrent urinary tract infections and/or pneumaturia.

Fistulation can occur into other organs, such as the vagina or small intestine, and occasionally enterocutaneous fistulae may occur.

Generalized peritonitis associated with diverticular disease is due to the presence of free pus, faeces, or both, within the peritoneal cavity. Faecal peritonitis occurs where there has been necrosis of the intestinal wall resulting in the leakage of faeces into the peritoneal cavity. Patients are often gravely ill with marked peritonism and septic shock.

Bleeding sometimes occurs from vessels at the neck of a diverticulum and tends to be profuse - such blood loss usually arises from a single diverticulum, most frequently situated in the right colon.

Diverticular disease cannot be held responsible for occult lower gastrointestinal bleeding leading to an iron deficiency anaemia; in these situations other causes should be sought, such as neoplasia or angiodysplasia.

Inflammatory changes with associated scarring from previous episodes of acute diverticulitis and smooth muscle hypertrophy may be sufficient to cause a complete blockage of the colonic lumen and precipitate acute large bowel obstruction. Incomplete obstruction resulting from scarring may result in a variable bowel habit and intermittent colicky abdominal pain. Stricturing as a result of diverticular disease can be indistinguishable from malignancy on radiological investigation.

Diverticulosis is detected readily by both barium enema and contrast enhanced computed tomography (CT). Double contrast barium enema will demonstrate diverticulae, any strictures present and may also be helpful in demonstrating the presence of fistulae.

In areas of severe diverticulosis it may be impossible to safely exclude small polyps or carcinomas, and a colonoscopy or flexible sigmoidoscopy is indicated if doubt exists. Double contrast barium enema is deferred in the presence of acute diverticulitis and is usually performed 4-6 weeks after the acute episode has settled.

In acute situations other imaging modalities such as CT and/or ultrasound scanning provide the mainstay of investigation.

Colonoscopy is easily performed as an outpatient procedure. It clearly demonstrates the presence of diverticulae and any other mucosal abnormalities. It is the procedure of choice when patients present with rectal bleeding or where a barium enema has failed to adequately delineate an area of the colon. Colonoscopy, however, may be difficult in the presence of extensive diverticular disease due to spasm, rigidity and the presence of the diverticulae themselves.

Computerised tomography and ultrasound scanning Contrast enhanced CT scanning is the investigation of choice in patients with acute diverticultis when the characteristic colonic wall thickening with inflammation of pericolic fat are frequently seen. In complicated cases, abscesses, extraluminal gas and extraluminal contrast may all be detected by CT scanning. Drainage of intra- abdominal abscesses under CT guidance is practiced in many units and can prevent the need for operative intervention in the acute setting. Ultrasound scanning, although less sensitive, can also demonstrate wall thickening and the presence of significant abscesses.