AREAS OF EXPERTISE

What are diverticulae?

A diverticulum is a pouch-like structure that can form through points of weakness in the muscular wall of the colon (ie, at points where blood vessels pass through the wall).
Diverticulosis affects men and women equally. The risk of diverticular disease increases with age. It occurs throughout the world but is seen more commonly in developed countries.

What causes diverticular disease?

Diverticulosis — Diverticulosis merely describes the presence of diverticula. Diverticulosis is often found during a test done for other reasons, such as flexible sigmoidoscopy, colonoscopy, or CT Colonography. Most people with diverticulosis have no symptoms and will remain symptom free for the rest of their lives.
A person with diverticulosis may have diverticulitis, or diverticular bleeding.

Diverticulitis — Inflammation of a diverticulum (diverticulitis) occurs when there is thinning and breakdown of the diverticular wall. This may be caused by increased pressure within the colon or by hardened particles of stool, which can become lodged within the diverticulum.
The symptoms of diverticulitis depend upon the degree of inflammation present. The most common symptom is pain in the left lower abdomen. Other symptoms can include nausea and vomiting, constipation, diarrhea, and urinary symptoms such as pain or burning when urinating or the frequent need to urinate.
Simple diverticulitis, which accounts for 75 percent of cases, is not associated with complications and typically responds to medical treatment without surgery.

Complicated diverticulitis occurs in 25 percent of cases and usually requires surgery. Complications associated with diverticulitis can include the following:
•    Abscess: a localized collection of pus
•    Fistula: an abnormal tract between two areas that are not normally connected (eg, bowel and bladder)
•    Obstruction: a blockage of the colon
•    Peritonitis: infection involving the space around the abdominal organ
•    Sepsis: overwhelming body-wide infection that can lead to failure of multiple organs

When to suspect diverticulosis

Diverticulosis is often found during tests performed for other reasons.

Barium enema – This is an x-ray study that uses barium in an enema to view the outline of the lower intestinal tract. This is an older test and has been largely replaced by computed tomography (CT) scan.

Flexible sigmoidoscopy – This is an examination of the inside of the sigmoid colon with a thin, flexible tube that contains a camera.

Colonoscopy – This is an examination of the inside of the entire colon. 

A CT scan is often used to diagnose diverticulitis and its complications. If diverticulitis (not just diverticulosis) is suspected, the above three tests should not be used because of the risk of perforation.

How diverticulae are treated

Diverticulosis — People with diverticulosis who do not have symptoms do not require treatment. However, most clinicians recommend increasing fiber in the diet, which can help to bulk the stools and possibly prevent the development of new diverticula, diverticulitis, or diverticular bleeding. Fiber is not proven to prevent these conditions in all patients but may help to control recurrent episodes in some.  Fruits and vegetables are a good source of fiber. The fiber content of packaged foods can be calculated by reading the nutrition label

Diverticulitis — Treatment of diverticulitis depends upon how severe your symptoms are.

Home treatment — If you have mild symptoms of diverticulitis (mild abdominal pain, usually left lower abdomen), you can be treated at home with a clear liquid diet and oral antibiotics. However, if you develop one or more of the following signs or symptoms, you should seek immediate medical attention:

Temperature >100.1°F (38°C)
Worsening or severe abdominal pain
An inability to tolerate fluids

Hospital treatment — If you have moderate to severe symptoms, you may be hospitalized for treatment. During this time, you are not allowed to eat or drink; antibiotics and fluids are given into a vein.
If you develop an abscess of the colon, you may require drainage of the abscess (usually performed by placing a drainage tube across the abdominal wall) or by surgically opening the affected area.

 

Surgical treatment for diverticulosis/diverticulitis

Surgery — If you develop a generalized infection in the abdomen (peritonitis), you will usually require an emergency operation. A two-part operation may be necessary in some cases.
-The first operation involves removal of the diseased colon and creation of a colostomy. A colostomy is an opening between the colon and the skin, where a bag is attached to collect waste from the intestine. The lower end of the colon is temporarily sewed closed to allow it to heal .
Approximately three to six months later, a second operation is performed to reconnect the two parts of the colon and close the opening in the skin. You are then able to empty your bowels through the rectum. Sometimes patients require up to a year to recover from the first operation, depending on how sick they were.
In non-emergency situations, the diseased area of the colon can be removed and the two ends of the colon can be reconnected in one operation, without the need for a colostomy.

Surgery versus medical therapy — An operation to remove the diseased area of the colon may not be necessary if you improve with medical therapy. However, people who are treated with an operation are felt to be cured, since only 15 percent of people develop further diverticulosis after surgery and only 2 to 11 percent of people need further surgery.
Thus, surgery may be recommended for people with repeated attacks of diverticulitis or if there are severe or repeated episodes of bleeding. The decision depends in part upon your other medical conditions and ability to undergo surgery.
Some healthcare providers recommend surgery after the first attack of diverticulitis in people who are less than 40 to 50 years. The reason for this is that the disease may be more severe in this age group and there may be an increased risk of recurrent disease that will ultimately require surgery. Thus, having surgery at a young age could potentially eliminate the chances of developing worsened disease. The decision to undergo surgery ultimately depends upon your surgeon's recommendations.
In many cases, an elective operation can be performed laparoscopically, using small incisions, rather than the typical vertical (up and down) abdominal incision. Laparoscopic surgery usually allows you to recover more quickly and shortens the hospital stay.

Recovery from diverticulitis — After an episode of diverticulitis resolves, if you have not had a recent colonoscopy, the entire length of the colon should be evaluated to determine the extent of disease and to rule out the presence of abnormal lesions such as polyps or cancer. Recommended tests include colonoscopy, barium enema and sigmoidoscopy, or CT colonography.

Diverticular bleeding  Most cases of diverticular bleeding resolve on their own. However, some people will need further testing or treatment to stop bleeding, which may include a colonoscopy, angiography (a treatment that blocks off the bleeding artery), bleeding scan, or surgery.

Diverticular colitis Patients with diverticular disease can develop a segmental colitis most commonly in the sigmoid colon. Segmental colitis associated with diverticula (SCAD) or diverticular colitis is characterized by inflammation in the interdiverticular mucosa without involvement of the diverticular orifices. Patients with segmental colitis associated with diverticulosis (SCAD) typically present with chronic diarrhea, cramping abdominal pain primarily in the left lower quadrant, and in some cases intermittent hematochezia The optimal treatment of segmental colitis associated with diverticulosis (SCAD) has not been well defined and different treatment regime includes Anthibiotics and Luminal antiinflammatory.