Taking the Mystery Out of "Tics" (Diverticulosis)

Pathophysiology

Diverticulosis is basically outpouches in the colon or weaker areas in the colon wall. In itself, it doesn't cause any problems. These diverticula can be in other parts of the GI tract, and we will touch on those. Diverticulosis does not cause any pain or issues with bowel movements, so people are not aware that they have them. But conditions can change, and as a result of inflammation, diverticulitis will occur. We will look at that in detail in another article.

Most diverticula are found in the large colon and, more specifically, in the ascending and sigmoid areas. The weaker parts of the colonic wall where they develop is where the mucosa and submucosa herniate through the muscularis¹. The vasa recta (straight capillaries off of the arcades in the mesentery) are close to these herniations and are the reason they can be prone to bleed¹.

Cause

Scientists have not figured out exactly how the diverticulum develops, but there are theories. One idea is that when the colon has peristalsis issues such as spasms or intestinal dyskinesia (increased or decreased movement due to the nervous system), it can lead to the development of diverticulosis². Another thought is that the intraluminal pressure inside the colon is high, as in constipation, leading to the increased chance of diverticulosis².

Some studies that researched diverticulosis have found a connection in patients with a low-fiber diet and/or one that includes a high amount of red meat¹.  These patients are thought to be prone to develop diverticulosis. As we know, red meat causes inflammation and is connected to colon cancer. Increasing fiber can help patients with complications from diverticulosis, although it won't change anything with uncomplicated diverticulosis¹. 

On the other side of that coin, Rezapour states in his article that low-fiber diets don't increase a person's chances of having diverticulosis². As mentioned above, there is the theory that constipation causes diverticulosis because of higher pressure and less motility in the colon². But that has been found to have conflicting outcomes in studies, as shown in the latter mentioned article¹. 

Diverticula are one of the mysteries in the GI world. So remember that there is no full explanation as to why patients develop them. As we saw, the colon wall structure and motility can be a factor, as well as fiber intake and activity level. Also, genetics are thought to play a part in the development of diverticulosis¹.

Genetics

Along with environmental factors, genetics is becoming an additional consideration for diverticular disease². This is thought to play a role because, in Western countries, diverticulosis is mainly on the left side of the colon, while in Asian countries, it's on the right side². Then the question is, what about Asian people who live in a Western country? The Japanese who live in Hawaii and eat an expanded Western diet continue to have diverticulosis on the right side². Twins have also been studied for the prevalence of diverticulosis, and they conclude that about 40 to 50% of diverticulosis is hereditary².

Complications

The largest issue with diverticular disease is that it can bleed easily. Patients on blood thinners are at a higher risk of having such a bleed. This can be life-threatening, but many times, the bleeding will stop on its own or once the patient gets treatment in the hospital. The only symptom is blood coming from the rectum. Blood from the rectum can be from many different sources, such as colon cancer, abscess, colitis, ulcers, etc.². Any time a patient sees blood, whether bright red or dark maroon color, a trip to the doctor and/or emergency room is in order. On rare occasions when the patient has multiple bleeding episodes, surgery can be considered, although it's not such a popular option these days².

Treatment

Other than surgery, what treatment is there for diverticulosis? Since there is no ideal treatment, we will go by what some of the present research shows. To decrease intestinal spasms, eating more fiber and drinking more water are recommended². Decreasing the amount of red meat is thought to be linked to diverticulosis, but that remains questionable².

Most patients will find out they have diverticulosis by undergoing a colonoscopy and being diagnosed with it. Bleeding is the most common problem associated with diverticulosis. There are several ways to stop bleeding in the GI tract during a colonoscopy, such as:

1. cauterization
2. injection of epinephrine
3. metal clips

Usually, by the time the patient has the colonoscopy, the bleeding has stopped, but ruling out other causes is important.

Diverticulosis in Other Parts of the GI Tract

A diverticulum can be found in the following areas of the GI tract:

• Zenker's diverticulum -  in the upper esophagus 
• Mid or lower esophagus
• Duodenum and jejunum
• There are two congenital types - Meckel's (small percentage require surgery) and Killian-Jamieson (also in esophagus)

The gastric portion of the GI tract doesn't usually see diverticulum, and the above-mentioned are uncommon.

Conclusion

In conclusion, we now know that diverticular disease is a multifactorial disorder.  It has genetic ties, as we see in the difference in location in the colon between Western and Asian populations. Diverticulosis is not in itself a problem. It has no symptoms, people aren't aware of it unless they have a colonoscopy to diagnose it.

Although doctors and researchers are not completely sure of its cause, diverticulosis is very popular in the United States. It is the 8th most common issue, with almost 3 million diagnosed in 2010². We do know that the chances of having diverticular disease increase with age². The increase in obesity in the United States over the past few decades has correlated with the increased number of patients diagnosed with diverticular disease². 

Years ago, doctors told patients not to eat peanuts, strawberries, or anything with seeds. Now, there aren't any dietary restrictions.

There are conflicting theories, with none of them coming out on top as to what contributes to a patient having diverticulosis. The things that doctors and researchers recommend are good for us to practice anyway, such as increased activity, less red meat, drinking plenty of water, and a higher intake of fiber. So until we have a definite reason for the cause of diverticulosis, we will consider the present concepts.

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References

1 NIH: Diverticulosis

2 NIH: Diverticular Disease: An Update on Pathogenesis and Management