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INTRODUCTION

Diverticular disease and colonic volvulus are common benign colonic conditions that can cause patients significant symptoms, impair of quality of life, and on occasion lead to fatal outcomes without treatment. Management at times can be challenging as decisions for surgical intervention must be carefully balanced against the patient’s relative procedural risks and comorbidities, which also can be significant. In this chapter, we discuss the current understanding of these 2 pathologies.

DIVERTICULAR DISEASE

Colonic diverticula are the most common structural abnormality of the bowel and constitute 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, especially in Asia. The prevalence of clinically apparent diverticular disease has increased over the past 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, over the past 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% to 66% in their ninth decade.6 Most patients with diverticulosis do not require surgery; however, complications of diverticular disease may require surgery. Such surgery can be challenging, and good outcomes rely on timely and appropriate intervention.

The terms used include diverticulum (diverticula—plural); diverticulosis, which indicates asymptomatic diverticula; diverticulitis (simple or complicated), or diverticula with inflammation; and diverticular disease, which is 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 Edwin Beer.10 This seminal work on the pathophysiology of diverticular disease reviews the medical literature on diverticular disease at the turn of the 19th century. Beer summarized the use of cadaveric and animal experiments to identify diverticula associated with colonic wall blood vessels and ascribes the cause of diverticulitis to hard fecal matter lodged within the diverticulum.11 He described the ensuing pathologic processes of mucosal ulceration, acute inflammation, abscess formation, colonic perforation, and fistulation. Beer also describes the process of cicatricial contraction caused by marked “connective ...

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