Management of Diverticulitis
By Gregory D. Kennedy, MD, PhD
Diverticulitis is a common problem worldwide. It can be managed with medical therapy, but surgical treatment should be considered in specific situations. Close collaboration between the primary care physicians, surgeons, and, in certain cases, gastroenterologists, can improve a patient’s quality of life. When elective surgery is deemed necessary, a laparoscopic approach is considered the gold standard.
What is diverticulitis?
Diverticuli are outpouchings that can occur anywhere along the gastrointestinal tract. We will limit our discussion to diverticuli of the large intestine.
The cause of colonic diverticuli is not well understood, but they are thought to occur as a result of dyscoordinated contractions in the colon. These contractions result in abnormally high pressure inside the colon which causes the inner lining (mucosa) to push out through the wall of the colon at natural areas of weakness — those points where blood vessels penetrate the wall.
To fully understand diverticulitis, we must first draw a distinction between –osis and –itis. Diverticulosis is the presence of diverticuli of the intestine and is quite common. It is estimated that almost 50% of the U.S. population over the age of 60 is afflicted with diverticulosis. Use of the term diverticulitis indicates that the diverticuli have become inflamed causing symptoms. While the cause of the inflammation is not completely understood, it is thought that a diverticulum or a series of diverticuli become blocked trapping bacteria in a closed space which then form into a localized infection. This small infection can result in rupture of the diverticulum causing severe generalized abdominal pain.
While diverticulosis is quite common, the incidence of one episode of diverticulitis is estimated to be only about 4% of those with diverticulosis. Having one episode of diverticulitis increases the risk of having more attacks. The risk for a second attack is about 10%; and of those, there is about a 15% of having a third attack; and so on.
What are the symptoms?
Diverticulitis presents with a symptom complex that is consistent with an infection.
How is it diagnosed?
The diagnosis of mild diverticulitis is most commonly made by a thorough history and physical. However, because irritable bowel syndrome can often present with similar symptoms as mild diverticulitis, a more thorough workup is often required. Patients who have symptoms consistent with diverticulitis should have a workup including:
How is diverticulitis managed?
To fully understand how to manage diverticulitis, we must consider emergency and non-emergency presentation of the patient. Management of these two groups of patients is different, and surgery may or may not play a role in either.
The patient who presents with a perforation most often has severe abdominal pain, fevers and may even have signs of sepsis (low blood pressure, high heart rate, rapid breathing, etc). These patients often come into urgent care or the emergency room. Fluid resuscitation with intravenous fluids and a CT scan is required to fully evaluate this patient. It is important to note that the decision to operate is not made by the results of the CT scan but rather based on the clinical presentation. The patient who is septic requires an operation after aggressive fluid resuscitation regardless of the CT scan findings. Patients with evidence of a perforation by CT scan can be managed non-operatively provided they are stable. This decision should be made by a surgeon with expertise in managing patients with diverticulitis.
A patient who has presented with their first bout of mild diverticulitis can be easily managed in the outpatient setting with oral antibiotics and diet modification. Antibiotic choice would need to cover enteric flora, which implies gram positive and negative as well as anaerobic bacteria. Most commonly ciprofloxacin and metronidazole are prescribed, but an extended spectrum beta-lactam such as amoxicillin with clavulanic acid is a reasonable alternative. The antibiotics should be continued for at least 10 days. Dietary changes should include a low-fiber diet until the pain is improved. Once the pain has resolved, the patient should be encouraged to enjoy a high-fiber diet and consider a fiber supplement. I do not recommend patients refrain from eating foods with seeds or husks unless they experience pain when they eat these foods.
Who should have a segmental colon resection?
Patients who have multiple repeated bouts of diverticulitis may benefit from an elective segmental colon resection. Given that the sigmoid colon is most frequently involved, the operation typically would require removal of the entire sigmoid colon. While there is no absolute number of bouts that would necessitate elective surgery, I generally would not consider elective surgery until after the third or fourth bout.
Sigmoid colectomy is a reliable way to prevent the recurrence of sigmoid diverticulitis. However, it will not prevent the recurrence of diverticulitis in general as frequently patients have diverticuli throughout their colons. Patients should realize that the goal of surgery is to decrease the risk for another bout of diverticulitis back down to the general population of approximately 4%.
For More Information
UW Health’s Colon and Rectal Surgery Program is the largest colon and rectal surgery specialty group in Wisconsin. Its providers offer a multidisciplinary approach to the evaluation and treatment of disorders of the colon and rectum — with an emphasis on minimally invasive procedures — through the UW Health Digestive Health Center.
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