Diverticular Disease

WHAT IS THE DIFFERENCE BETWEEN DIVERTICULOSIS AND DIVERTICULITIS?

DIVERTICULOSIS:

Diverticulosis refers to the condition where small pouches or sacs develop in the colon wall, most often in the sigmoid or left colon, that are not inflamed nor infected. The individual sacs or pouches are called a diverticulum (plural; diverticula). There are many risk factors for diverticulosis such as a low fiber diet, nonsteroidal anti-inflammatory drugs (NSAIDs), diminished immune status, alcohol, and age.

Diverticulosis is highly prevalent, and the proportion of the population with diverticulosis increases notably with age. It is rare for people under the age of 30 to have diverticulosis, but its prevalence rises significantly among older adults. Approximately 30-40% of individuals aged 60 years old have diverticulosis, increasing to 50-80% among those aged 80 years.

People with diverticulosis usually have no symptoms. It is often discovered as an incidental finding during colonoscopy. No treatment is necessary as these are neither inflamed nor infected.

Rarely, bleeding can occur due to a diverticulum, and this may need to be treated with a procedure or surgery if it does not stop on its own. Bleeding may be mild or severe and usually occurs independently of diverticulitis episodes. Most cases of diverticular bleeding resolve with supportive care in the hospital. Some patients require minimally invasive techniques such as angiography or colonoscopy to control bleeding. In extreme instances, bleeding may persist, and in these situations surgery may be required to remove a portion or the entirety of the colon.

DIVERTICULITIS:

Diverticulitis occurs with inflammation of one or more of these pouches in the colon. Most often, attacks are mild in nature and resolve with conservative measures such as antibiotics and diet changes. It is estimated that 10-20% of people with diverticulosis will experience diverticulitis in their lifetime.

After experiencing an attack of diverticulitis, individuals are at risk for recurrent episodes and potential for “complicated” attacks (See below). Identifying the exact risk of a recurrent attack of diverticulitis in someone with a history of attacks is challenging, as it depends on various factors, including the patient’s age and the severity of the initial attack.

WHAT CAUSES DIVERTICULOSIS TO BECOME DIVERTICULITIS?

The exact cause of diverticulitis is unknown. People used to theorize that foods such as nuts, seeds, and popcorn could get trapped in the diverticula and cause inflammation, leading to diverticulitis. This theory is FALSE. On the contrary, newer studies suggests other factors that influence diverticulitis may include:

1. Bacterial microbiome: Certain bacteria may contribute to the rhythmic contraction (motility) of the colon. Alterations in this bacteria can lead to diverticulitis. Probiotics may help replenish the bacteria of the colon

2. Lack of fiber: This causes stool to be dry, creating increased colon pressure, which causes protrusion of the colon wall’s weakest points. Increasing fiber in an individual’s diet helps bulk stool to allow for easier movements. High fiber diet may be helpful in preventing attacks but it is usually recommended to be on a low fiber diet during an active flare-up.

3. Lack of fluids: Studies have shown that diverticulitis is more common in the summertime. Newer theories suggest that keeping your stools well hydrated is essential to promote regular, consistent bowel movement. This may be helpful in preventing a future attack.
   
   

WHAT ARE THE TYPES OF DIVERTICULITIS?

Diverticulitis can be classified into different categories based on severity and resulting effects of inflammation and infection.

Uncomplicated diverticulitis - This refers to localized inflammation of the large intestine. Symptoms of uncomplicated diverticulitis commonly include abdominal or pelvic pain, abdominal tenderness, and fevers. Alterations in bowel habits such as diarrhea or constipation may also occur. Additionally, individuals might experience urinary issues such as increased urgency and more frequent urination. Surgery is often not necessary but may be recommended to patients with recurrent or worsening attacks, those with an increase in frequency and severity of attacks, immunocompromised patients, and individuals whose quality of life is affected. Acute attacks of uncomplicated diverticulitis are usually treated with antibiotics in the outpatient setting.

Complicated diverticulitis – This refers to intense inflammation of the bowel that leads to other severe issues. In most instances, surgery is recommended but can usually be performed in an elective setting to decrease the risk for needing an ostomy. There are a few types of complications that can occur due to “complicated diverticulitis”.

1. Abscess: This is a large collection of pus or infected fluid that results from rupture of an inflamed diverticulum. Abscesses can often be drained with a radiology procedure, or inflammation can be reduced with antibiotics. Patients with large abscesses (over 2 inches) have a greater chance of recurrent attacks and therefore surgery is usually recommended to prevent future attacks. Ideally, this surgery can be done electively.

2. Perforation: This is when a rupture or leakage of the large intestine occurs, spreading fecal material or pus to other regions of the abdominal cavity. Emergency surgery is usually necessary to control the resulting infection .

3. Fistula: This is an abnormal connection that allows fecal matter and gas to transfer from the colon to other nearby organs:

   • Bladder (colovesical fistula). Cloudy urine with stool matter, passage of air with the urine, or recurrent urinary tract infections (UTIs) may indicate the development of a fistula to the bladder. 

   • Small intestine (enterocolic fistula). Primarily diagnosed with CT scan or during surgery. Some patients may experience severe diarrhea due to the bypass of bowel contents

   • Vagina (colovaginal fistula). Patients may experience gas, stool, or foul smelling discharge from the vagina. This is more common in patients who have had a hysterectomy.

   • Skin (enterocutaneous fistula). This usually occurs after drainage of an abscess. Patients may see signs of persistent drainage through their skin.

4. Stricture: This is a narrowing along the lining of the large intestine due to inflammation and scarring. This can make it difficult for waste to pass through the bowel and cause other side effects such as cramping, bloating, and abdominal pain. Thin stools or constipation may indicate the presence of a stricture.
   
   

HOW IS DIVERTICULITIS DIAGNOSED?

The most common tests for diagnosing diverticulitis and its complications typically include blood tests, urine tests, and a computed tomography (CT scan) of the abdomen and pelvis. Among these, a CT scan is considered the most reliable method for diagnosing diverticulitis. It provides detailed information about the affected part of the colon and can detect complications such as an abscess, stricture, fistula, or perforation.

Blood and urine tests may show signs of infection but these are not specific enough tests to diagnose diverticulitis. A CT scan remains the gold standard for diagnosis of diverticulitis.

A colonoscopy is generally recommended about 6-8 weeks after recovery from an initial attack of diverticulitis to examine for other possible causes for recent illness (such as inflammatory bowel disease, ischemic colitis, or mass/cancer).

HOW CAN DIVERTICULITIS BE TREATED?

The vast majority of patients do not require hospitalization or surgery for diverticulitis. Patients with “uncomplicated diverticulitis” are often treated with oral antibiotics and a restricted diet consisting of low fiber or liquids until symptoms resolve. Patients who do not get better with treatment may have to be admitted to the hospital for hydration and intravenous (IV) antibiotics.

Some patients with recurrent episodes of “uncomplicated diverticulitis” may benefit from surgical treatment to improve quality of life and reduce the risk of recurrent episodes. Several considerations influence the decision for surgery. These factors include the patient’s general health, current medical condition, frequency of flare-ups, severity of flare-ups, and how these flare-ups affect one’s quality of life. It is recommended that patients have these discussions with their surgeon regarding the risks and benefits of surgery in order to make an informed decision.

• Partial colon resection - This involves removing the affected segment of the colon, usually the sigmoid colon. If safe to do so, reconnection of the colon occurs between healthy segments of the colon and the rectum. This surgery can usually be accomplished with minimally invasive techniques using laparoscopy or robotic surgery. In certain situations, these surgeries may require a temporary or permanent ostomy.

• Ostomy creation – An ostomy involves connecting the intestine to the abdominal wall. This allows passage of stool to bypass the area of infection. An ostomy may be either temporary or permanent depending on the patient’s overall health status and anatomic factors.
  
  

ABOUT COLON AND RECTAL SPECIALISTS

Colon and Rectal Specialists was founded in 1913. We are a group of dedicated fellowship-trained colorectal surgeons. We are experts in the surgical and non-surgical treatment of diseases of the colon, rectum, and anus. Our surgeons have all completed advanced surgical training in the treatment of these diseases in addition to full general surgical training. We are well-versed in the treatment of both benign and malignant diseases of the colon, rectum, and anus and are able to perform routine screening examinations and surgically treat conditions when indicated. 

ABOUT C.A.R.E.S. CENTER

Colon and Rectal Endoscopy and Surgery (CARES) Center is our state-of-the-art Ambulatory Surgery Center. Our center has been accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) and has been given Medicare Deemed Status by CMS. We perform a variety of services including: screening colonoscopies, hemorrhoidectomy, abscess and fistula surgery, fissure surgery, pilonidal surgery, and surgery to treat fecal incontinence. Learn more about us at www.crspecialists.com