Diverticular disease


Topic Completed: 1 May 2013

Minor changes: 18 December 2020

Copyright: 2003-2021,, Inc.

PubMed Search: colonic diverticulosis

Hanni Gulwani, M.B.B.S.
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Cite this page: Gulwani H. Diverticulosis. website. Accessed October 16th, 2021.
Definition / general
  • Diverticulum: blind pouch leading off alimentary tract, lined by mucosa that communicates with gut lumen
  • Congenital: have all 3 layers of bowel wall (includes Meckel diverticulum)
  • Acquired: lack or have attenuated muscularis propria due to focal weakness in wall and increased intraluminal pressure
  • Note: colonic longitudinal muscularis propria layer is gathered into taeniae coli; focal defects occur where nerves and arterial vasa recta penetrate inner circular muscle wall
Clinical features
  • Associated with Western diets (low fiber causes prolonged transit time, low volume stools, increased intraluminal pressure); rare in Asia, Africa, South America where high residue diet is common (World J Gastroenterol 2009;15:2479, J Clin Gastroenterol 2006;40:S126)
  • Rare before age 30, 50% occur at age 60+ but only 20% develop symptoms
  • May regress early in development or become more numerous / prominent over time
  • May coexist with inflammatory bowel disease
  • Have higher risk of colonic polyps (World J Gastroenterol 2008;14:2411)
  • Symptoms: cramping, discomfort, constipation, distention, sensation of inability to completely empty rectum; alternating constipation and diarrhea; motor abnormalities may be due to loss of interstitial cells of Cajal and glial cells (J Clin Pathol 2005;58:973)
  • Complications: hemorrhage (may be massive), perforation with abscess resembling a mass or forming a sinus tract, diverticulitis / peritonitis, fistula into bowel or bladder, obstruction, adhesions
Left versus right sided disease:
  • Left sided disease: common in West, affects sigmoid but not rectum, older individuals
  • Right sided disease: more common in Far East, may mimic appendicitis; in Japan, has similar features to left sided disease (Int J Colorectal Dis 2002;17:365); other reports indicate patients may be younger with fewer clinical problems (Dis Colon Rectum 1995;38:755, Korean J Intern Med 2010;25:140)
  • Single true diverticular disease of right colon is usually of congenital type, affects younger age group, may be associated with angiodysplasia; multiple false diverticuli are associated with cecal carcinoma or large adenomas (BMC Res Notes 2011;4:383)
Case reports
  • High fiber diet and poorly absorbed antibiotics (Digestion 2006;73:58)
  • Resection for perforation and peritonitis and for repeated attacks of diverticulitis
Diagrams / tables

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Physiological activity

Gross description
  • Grossing: fix intact specimen with formalin for 24 hours before dissection
  • Multiple, small, flask-like invaginations present along prominent taeniae coli, filled with mucin or stool but easily emptied, may bulge into serosa
  • Thick and corrugated circular muscle with prominent accordion-like mucosal folds; in severe cases, bowel is segmented and shortened
Gross images

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Multiple diverticula

With bowel wall stenosis

Blue-gray diverticula

Perforated single true diverticulum

False diverticulum

Microscopic (histologic) description
  • No muscle layer around diverticula except for residual bundles of muscularis mucosa
  • Inflammation due to obstruction or perforation, may dissect into adjacent pericolic fat, causing fibrotic thickening resembling colon carcinoma; may have Paneth cells (Dig Dis 2012;30:29)
  • Intramucosal ganglion cells are common (Pathology 2008;40:470)
  • Mucosal changes in diverticula in uncomplicated diverticulosis include increased lymphoid infiltrate, lymphoglandular complexes, mucin depletion, mild cryptitis, architectural distortion, Paneth cell metaplasia, ulceration (J Clin Gastroenterol 2004;38:S11)
Microscopic (histologic) images

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Central lumen with surrounding mucosa

Paneth cells

Focal inflammation

Angiodysplastic changes

False pulsion type diverticulum

Differential diagnosis
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