Diverticular Disease-related Colitis
Sharon K. Bihlmeyer, MD
Key Facts
Terminology
Ulcerative colitis-like variant (chronic segmental colitis in distribution of diverticula)
Crohn-like variant (Crohn-like reaction to diverticulitis in resection specimen)
Clinical Issues
Presents w/hematochezia, abdominal pain, diarrhea
Median age is 64 (range 40-86 years)
Predominately involves descending and sigmoid colon (with rectal sparing)
Treatment directed toward diverticular disease suppresses symptoms
Macroscopic Features
Thickened bowel wall
Redundant or polypoid mucosal folds
Microscopic Pathology
Both variants have chronic changes with basal and diffuse plasmacytosis with crypt distortion
Ulcerative colitis-like variant is not associated with diverticulitis
Crohn disease-like variant associated with diverticulitis
Deep ulcers extend into muscularis propria
Top Differential Diagnoses
Ulcerative colitis
Crohn disease
Infectious disease
Diversion colitis
Nonsteroidal anti-inflammatory drug-associated colitis
 Clinical photograph shows an endoscopic image of diverticula (outpouchings from colonic lumen)  . The surrounding mucosa is erythematous and granular, suggesting inflammation. |
 Hematoxylin & eosin shows a biopsy specimen with features of chronic colitis with dense lymphoplasmacytic inflammation of the lamina propria, crypt distortion  , and crypt abscesses  . |
TERMINOLOGY
Definitions
Ulcerative colitis-like variant
Chronic segmental colitis in distribution of diverticula
Restricted to mucosa
Not related to diverticulitis
Crohn-like variant
Crohn-like reaction to diverticulitis in resection specimen
ETIOLOGY/PATHOGENESIS
Unknown
Diverticulitis may initiate inflammatory changes, which resemble Crohn disease
Multifactorial
Mucosal prolapse
Fecal stasis
Postulated as etiological factor in inflammatory bowel disease
Secondary to changes in bacterial flora and to bacterial enzyme activity
Stasis in diverticulosis may have same effect
Mucosal ischemia
Immunologically Mediated
Theorized that development of diverticular disease-related colitis is similar to pathogenesis for inflammatory bowel disease
Environmental trigger such as bacterial antigen or antigens
Disordered or disproportionate immune response in genetically susceptible host
Inflammation-Mediated
Early mucosal inflammation usually confined to diverticular tips
Later inflammation extends to ostia of diverticula and surrounding mucosa
CLINICAL ISSUES
Epidemiology
Incidence
0.2-1.4 cases per 100 colonoscopies
2% of patients that have both inflammatory bowel disease and diverticulosis
Age
Median age is 64 (range 40-86 years)
Onset of diverticular disease-related colitis is markedly later than that of inflammatory bowel disease
In age-matched controls
Gender
Equal incidence in both sexes
Ethnicity
Geographical differences in prevalence of diverticulosis
Prevalence of diverticulosis is highest in Western societies and those with Western-type diet
Prevalence of diverticulosis is lowest in societies with high-fiber diet
Site
Predominately descending and sigmoid colon
Rectal sparing
Presentation
Endoscopic Findings
Changes confined to distribution of diverticula
Colonic mucosa proximal and distal to diverticular segment is normal
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