Diverticular disease and Diverticulitis
Have you, or a loved one, suffered an attack of diverticulitis? The progressive, or sudden onset of belly pain, often located in the left lower region of your abdomen? A stomach ache that doesn’t go away, worsening in intensity over hours and days? The call to your doctor, perhaps the trip to an Emergency Room, where exam, labs and cat scans reveal inflammation and infection surrounding a section of your colon. For those with a mild attack, a prescription for antibiotics and discharge to home may be all that is needed. For some, admission to the hospital is necessary, for intravenous antibiotics, or perhaps drainage of an infected pocket of pus (abscess). For the unfortunate few with severe diverticulitis, immediate surgery to remove the damaged and infected section of colon may be necessary. Emergent surgery for patients with the most severe form of diverticulitis also carries the risk of needing a temporary colostomy.
What is Diverticulitis?
“Diverticulitis” describes the localized infection that follows rupture of a diverticula, located on the intestinal wall (most commonly the large intestine, or colon). A diverticula (or diverticulum) is an outpouching of the wall of the intestine, at an area of structural weakness. Think of it like a thin-walled bleb you might see on the surface of a bike tire inner-tube that is over inflated. The rupture of a diverticula allows stool and bacteria to escape out of the intestine and infect the surrounding area. If the rupture is small, or intra-mural, and the colon re-seals quickly, then the limited spillage of bacteria into the surrounding area may result in a small infection that the body can handle and overcome. With increasing amounts of bacteria and infection, the body may struggle to overcome the infectious challenge.
What causes diverticulitis?
Contrary to popular belief, eating seeds and nuts does NOT cause diverticulitis, nor does abstaining from seeds and nuts prevent another attack of diverticulitis from occurring in the future. So, if you enjoy peanuts with your ballgame, eat away! (Just chew your food thoroughly, which is always good advice).
There is no one simple explanation that completely describes the reasons people develop diverticula, and why a small percentage of that population will develop infectious diverticulitis. Among the various risk factors related to the development of diverticula and diverticulitis, large population studies have shown that diets high in red meat and low in fruits and vegetable increase diverticular symptoms by six-fold. Diets high in fiber and water may be protective by creating a stool that requires less transit time as it passes through the GI tract. These potentially softer larger more bulky stools may also require less segmental colonic pressure contraction to move forward. It makes sense that if the colon does not have to squeeze so hard to move the stool downstream, then risk of both forming diverticula as well as rupturing existing diverticula will be lower.
Risk of developing diverticulitis and recurrent diverticulitis
It is estimated that 50% or more of men and women have structural colon diverticula by age 60. Diverticula are being found in younger persons at increasing higher rates.
While diverticula (the outpouching) are common, the rupture and infection known as diverticulitis is less common, occurring in approximately 10%-20% of people with diverticula.
For people suffering the rupture and infection of diverticulitis, about 10%-20% will require hospitalization. Most people are successfully managed in the home setting, with oral antibiotics and a modified diet.
After an initial experience of diverticulitis, around 10%-20% of effected persons will experience additional future episodes, called recurrent diverticulitis.
For those who have experienced an attack of diverticulitis, consideration of future attacks, with the attendant pain and suffering, can create stress and anxiety. These unpredictable, recurrent diverticulitis events impact immediate work and personal schedules. The recovery period can be days or weeks till full resolution of abdominal pain and discomfort. It can become a consideration when planning future business or vacation travel (“…what if I were to get an attack while out of the country…”).
Surgical Considerations for Diverticulitis
For a person who has experienced an attack of diverticulitis they may be advised to consider surgical removal of the infected section of colon. Perhaps they have had multiple attacks over time, or experienced a prolonged slow smoldering recovery that significantly impacted their immediate quality of life. They are faced with the risk of future unpredictable recurrent attacks. In these situations, surgical removal of the diseased colon may be beneficial.
When a person is advised to consider surgical removal, the mental calculus involves guesstimating and comparing the potential risk, severity, and consequence of future diverticulitis attacks, against the risks and benefits of elective surgical management. When discussing this issue with our patients, we as surgeons generally organize our risk assessment around these categories:
What was the severity of the initial, or past attacks? Was the person hospitalized? Did they require intravenous antibiotics and/or prolonged oral antibiotics? Did they require procedures to drain abscess infection?
How many attacks has the person had in the past, and over what time frame? Has there been an escalation of attacks with shorter duration between events?
Is the person suffering a persistent low grade “smoldering attack” that has not completely resolved, despite more than one round of antibiotic treatment?
Has the person suffered additional complications from the diverticulitis infection, such as fistula communication to surrounding structures, such as bladder or vagina?
Does the person have specific considerations that make the consequences of a future attack more severe? Such as medical conditions, diabetes, immunosuppression, or lifestyle issues such as frequent travel outside of the country.
There are no easy “rules” about the indications for elective surgical care. Each case requires individualized assessment. During this time of decision-making a person needs an "honest broker"; someone who knows the data and can provide information and guidance toward the best decision for that person, at that time.
We are the "honest broker" you may be seeking. We offer individualized management. Through conversation and discussion at our initial consultation (history taking, physical exam, review of past data including hospital reports, labs, cat scans, colonoscopies) our goal is to organize with you all the information specific to your situation. Then, placing that information within the larger context of future risk and benefit, we provide treatment recommendations, both surgical and non-surgical.
As colon and rectal surgeons, our focus of specialty includes the management of diverticulitis. We often achieve surgical success incorporating minimally invasive techniques, assisted by laparoscopic or robotic technology. Please find information about our use of the laparoscopic and DaVinci robotic platforms through this link.