Chapter 32

Diverticular disease and colonic volvulus are common colonic conditions. Though benign in pathology, their management results in a major workload and the diseases are not without risk of major complications, including death. In this chapter we discuss the current understanding of these two pathologies.

Colonic diverticula are the most common structural abnormality of the bowel and is the fifth most costly gastrointestinal disorder in Western society.1,2 An acquired condition, diverticula usually affect the sigmoid colon in Western societies, but they are also found on the right colon in countries with diets rich in fiber. The prevalence of diverticular disease has increased during the last century,3 which probably reflects both an increase in detection and an aging population. Until 30 years ago, the proportion of patients requiring surgery or dying from diverticular disease was decreasing4; however, during the last 20 years, the rates of hospital admission and surgical intervention have increased, while inpatient and population mortality rates from diverticular disease have remained unchanged.5

Colonic diverticulum is an acquired condition with increased prevalence with increasing age. It affects fewer than 10% of people in their fifth decade of life, increasing to around 50–66% in their ninth decade.6 Most patients with diverticulosis don't require surgery; however, complications of diverticular disease may. Such surgery can be challenging and good outcomes rely on timely and appropriate intervention.

The terminologies used include diverticulum (diverticula—plural); diverticulosis—asymptomatic diverticula; diverticulitis (simple or complicated)—diverticula with inflammation; diverticular disease—diverticula with or without inflammation.

History

Diverticular disease was initially described by Littré in 1700 as saccular outpouchings of the colon.7 Cruveilhier is credited with the first clear and detailed description of the pathogenesis of diverticulitis and complicated diverticular disease.8 In 1899 Graser introduced the term “peridiverticulitis” and suggested that diverticula were caused by herniation of colonic mucosa through areas of penetration of the vasa recta. This is now well established as the pathogenesis of colonic diverticulosis.9 In contrast, the mechanism for diverticulitis was not identified until 1904 by Beer.10 He proposed that impacted fecal matter at the neck of the diverticulum caused inflammation and subsequent abscess and fistula formation.

Moynihan reported a case of peridiverticulitis in 1907 and underlined the difficulties in distinguishing diverticular disease from malignancy.11 Telling and Gruner's classic paper describing complex diverticular disease was not published until 1917.12 At this time the prevalence and pathophysiology of diverticular disease were well recognized, as were the complications, including acute diverticulitis, abscess, fistula, perforation, and obstruction.

The development of radiological imaging of the large intestine was important in establishing a diagnosis and documenting the extent of diverticular disease.13 In 1914, De Quervain and Case were the first to demonstrate colonic diverticula with x-rays.14,15

Etiology

Diverticular disease is a disease of Western populations. A number ...

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