Diverticulitis and Diverticulosis

What is diverticulitis ?

Diverticulitis is a common gastrointestinal disorder found mainly in the left side of the large intestine, primarily the sigmoid colon. Diverticulitis develops from a condition called diverticulosis, which involves the formation of outpouches of the colon wall. Diverticulolsis is quite common and tends to occur after the age of 50. Diverticulitis results if one or more of these pouches (or diverticula) becomes inflamed. While left sided involvement is the rule, some patients may have diverticulosis and subsequent diverticulitis on the right side of the colon.

Risk factors believed to be important for developing diverticulosis includes: aging, low fiber diet and possibly lack of exercise. There are no known factors that cause diverticulosis to become diverticulitis.

What are the common signs and symptoms of diverticulitis ?

    Patients often present with the classic triad of symptoms:

  1. Left sided abdominal pain mainly over the lower left side (also known as left lower quadrant pain).
  2. Fever
  3. An elevation of the white cell count (blood test).

Patients may also complain of nausea or diarrhea; others may be constipated.

Other symptoms could include: vomiting, bloating, bleeding from your rectum, frequent urination, and difficulty or pain with urination.

Diagnosis: What tests may be done to prove that a patient has diverticulitis ?

Patients with the above symptoms are commonly studied with a computed tomography, or CT scan. The CT scan is very sensitive (it will detect 98% of all patients with diverticulitis).

Your doctor may also choose to obtain a barium enema. In this test, x-ray dye (barium) is injected through the rectum and pictures are taken to study the inside of the colon. While this test is sensitive for the diagnosis, it does not give information about the overall extent of the disease.

Your doctor should discuss the reasons for choosing one of these tests versus another.

What needs to be done if I have diverticulitis ?

Medical Management

A first time episode of diverticulitis is usually treated with conservative medical management, including bowel rest (i.e., ranging from nothing by mouth to liquids only), intravenous fluid, and antibiotics. Depending on the severity of your attack, this treatment plan may or may not require hospital admission.

Once your pain begins to resolve, most patients will be placed on a low residue diet. This low-fiber diet gives the colon adequate time to heal without needing to be overworked. Later, patients are typically placed on a high fiber diet as there is some evidence this lowers the risk for second and third attacks, known as recurrence.

Patient suffering one-time attacks typically do not require surgery so long as the attack resolved with medical therapy. Recurring attacks or more severe first-time cases may require surgery, either immediately or on an elective basis (see below). The decision to perform surgery for diverticulitis is always handled on a patient by patient basis so you should discuss your specific case with your doctor.

Surgical Therapy

In some cases, surgery may be required to remove the area of the colon most affected by the disease. For example, if the involved segment is the sigmoid colon, the procedure is known as a sigmoid colectomy.

You should understand that segmental colectomy only involves removing the infected or thickened area. Surgeons routinely leave other areas of diverticulosis behind to avoid removing large amounts of your colon. Only 4% of people who have surgery will have a repeat attack in the remaining bowel. However, repeat surgery is not usually warranted.

When is Surgery Indicated?

  • Repeated attacks of diverticulitis, (surgery usually advised after two to four attacks).
  • Diverticulitis causing partial or complete bowel blockage (obstruction).
  • Infected diverticulum leading to perforation of bowel contents into abdominal cavity, (also known as peritonitis or abdominal sepsis).
  • Communication (fistula) between the affected bowel and any surrounding organs such as bladder, uterus, skin.

Types of Surgeries:

Emergency Colectomy:

In more emergent cases, when there has been perforation to the intestine from diverticultis, two operations are usually involved.

  • The first operation takes care of the immediate problem by removing the infected bowel. Due to the local inflammation and infection in such situations, the bowel is usually not healthy enough to reattach and the patient is left with a colostomy. A colostomy is a temporary situation in which the end of the colon is brought up to the skin. Stool will pass through the colon through this hole or stoma into an attached bag. This will typically be left in place for 4-6 months to allow the infection and inflammation on the inside to heal.
  • The second operation entails putting the colon back together. This operation can be performed either open (through an incision) or laparoscopic (through multiple small incisions). This decision will be left to you and your surgeon.

Elective Colectomy:

More typically, elective surgery for diverticulitis occurs. As discussed above, this is called segmental colectomy and can be performed either open or laparoscopically.

In open surgery, a large abdominal incision is made. Through this incision the surgeon is able to remove the diseased intestine. Once the diseased bowel is removed the remaining colon is reconnected. With this, the patient is able to have normal bowel movements, the same as before the surgery.

In laparoscopic surgery, 3-5 small incisions are made in the abdominal wall through which instruments and a viewing tube (laparoscope) are inserted. A camera attached to the viewing tube sends images of the inside of the abdomen to a television screen. The surgeon looks at the screen to see what he or she is doing while using the instruments to perform the surgery.

Recent studies show that when laparoscopic colectomy is performed by an appropriately trained surgeon, the short- and long-term outcomes are better than with open surgery. This stems from shorter recovery time, reduced length of hospital stay and earlier return to daily activities. You should ask your surgeon about this approach and about his personal skill level and experience with laparoscopic colectomy.

Risks of laparoscopic colectomy for diverticulitis:

The risks of any surgery must be weighed against the risks associated with disease state requiring the intervention. In the case of recurrent complicated diverticulitis, the risks of ongoing inflammation and infection are greater than the risks described below and surgery is thus indicated.

    Major risks of laparoscopic colectomy for diverticultis can include but are not limited to:

  • Wound infection (1-3%) possibly requiring opening of wound, drainage, antibiotics and prolonged wound care.
  • Abdmominal cavity infection (1-3%) possibly requiring antibiotics, drainage of the infection via a catheter or reoperation to drain the infection.
  • Leakage from the re-connection points (anastomotic leak) (1-2%) resulting in infection and possibly drainage of the infection via a catheter or re-operation to drain the infection. Re-operation may also require creation of a temporary colostomy to allow the body time to heal the infection. This can typically be reversed 4-6 months later.
  • Bleeding from surgical sites (1-3%) requiring observation, blood transfusion or re-operation.
  • Recurrence of diverticultis (10%) in adjacent or remote areas of the colon requiring additional medical or surgical therapy.