Surgical Treatment of Diverticulitis

Diverticular disease essentially results from eating a diet that contains too little fiber.  Fiber itself is not ingested, but passes through the intestines basically unchanged.  This passing softens the stool and its passage.  Lack of fiber causes dry and small stools which require the intestinal muscles to contract with greater force to pass them along.  This generates a higher pressure in the large intestines.  The excess pressure leads to weak spots in the colon walls that eventually bulge out and form pouches called diverticula.  Existing weakness in the colon walls also contribute to the development of diverticula.  Most often, the pouches form in the sigmoid colon, which is the lower left part of the colon which connects to the rectum.  This area of the colon is subject to the highest amount of pressure because it is the narrowest portion of the large intestine.

Diverticulosis is very common, being found in more than half of Americans over the age of 60.  Only a small percentage of these people will develop the complication of diverticulitis.  Diverticulitis can lead to complications such as infections, perforations or tears, blockages or bleeding.  These complications always require treatment to prevent them from progressing and causing serious illness.  The diverticula may also get infected.  This is caused by stool or food that is not broken down and gets trapped, causing swelling and pain. 

A diverticulum can become infected with bacteria and rupture, causing diverticulitis.  Fever, pain, and tenderness of the lower left abdomen are common symptoms.  Constipation and diarrhea may also occur. Direct risk factors for diverticulitis are not known, but they may include older age or a low fiber diet.  To prevent diverticulitis, eat regular, nutritious meals containing high fiber foods, such as fruits and vegetables.  It is also vital to drink plenty of water and to watch for changes in bowel movements, get enough rest and sleep, and to avoid foods such as popcorn. 

Diverticular disease is most often found in men over the age of 40 and is rarely found in cultures with poor diets.  Retained and undigested foods mixed with bacteria accumulate in the diverticular sac, which forms a hard mass.  This substance cuts off the blood supply to the thin walls of the sac, which makes them more susceptible to attack by colonic bacteria.  Inflammation typically follows and may lead to perforation, abscess, peritonitis, obstruction, or hemorrhage.  On occasion, the inflamed colon segment may produce a fistula by adhering to the bladder or other organs. 

For uncomplicated divertusulosis, the primary physician may recommend a high fiber diet and the use of stool softeners.  An attack of acute diverticulitis may require hospitalization which will include a treatment regimen of antibiotics, intravenous fluids, and nasogastric suction, which is a procedure that relieves pressure in the intestine.  In most cases which require surgery, the surgeon will remove the diseased section of the intestine and joins the remaining sections together.  Some patients may require a temporary colostomy.  A colostomy is an operation to bring part of the large intestine to the abdominal surface to form a new opening for bowel movements.  Diverticulitis is usually mild and should respond well to antibiotics and changes in diet. 

Support For Those With Diverticulitis

Like any other disease or condition those suffering from diverticulitis benefit from support from family, friends and the medical community as well as from support groups designed to give information to those with diverticulitis and give them the chance to share stories and to feel a sense of understanding and connection with other going through the same things as they are. There are many local, and online support groups that individuals with diverticulitis can join.

Dealing with the surgery, diet changes and antibiotic therapy can be stressful for individuals with diverticulitis.

One-organization individuals with diverticulitis can go to for support and information is the National Digestive Diseases Information Clearinghouse (NDDIC). Located in Bethesda, MD, they can be reached by phone: 1-800-891-5389 or on the web at digestive.niddk.nih.gov/

The clearinghouse answers questions, presents reviews, creates and distributes publications and generally coordinates informative sources about digestive diseases including diverticulitis. You cannot get medical advice, but you can receive information that has been reviewed carefully for scientific accuracy, content and for the ability of the information to be understandable to the average non-medical individual.

Once on the site you can quickly locate topics regarding digestive diseases including other resources, statistics, information about clinical trials and guidelines and also awareness and prevention programs and series.

On their resources page you will find a link to MEDLINEplus which is a consumer-driven site linking consumers with doctor referrals and drug information.

There are articles and medical journals that you can access, as well as tools and resources including an image library, interactive health education tools, and a list of two other organizations where individuals can find more resources and support for those with diverticulitis and other digestive diseases.

Another helpful organization for those with diverticulitis is the Association of Gastrointestinal Motility Disorders, Inc. (AGMD). You can locate them online at agmd-gimotility.org

They are an educational resource on digestive motility disorders and function.

Another organization that has the goal of informing the public about digestive diseases, to help seek Federal funding for research, education and training and that represents members and their interests on the Federal and state level including how legislature affects digestive diseases is the Digestive Disease National Coalition. You can reach them online by going to:

www.ddnc.org

Support groups offer current information about the disease; offer ways for individuals to connect to services and support groups locally as well as to locate doctors in their location. Support groups can help individuals to connect with others who are going through exactly what they are going through so that they can get together to share what works and what doesn’t. Support groups give individuals the chance to know that they are not alone; that there are other caring individuals who are knowledgeable about what they are dealing with who can help with resources, tools, and an understanding ear.

Diverticulitis Diagnosis

Diverticulitis is a condition in which diverticuli in the colon rupture.  The rupture results in infection in the tissues which surround the colon.  The colon is the large intestine and is a long tube like striation that stores and then eliminates waste material.  As a person gets older, pressure within the colon causes bulging pockets of tissue, or sacs, that push out from the colon walls.  A small bulging sac pushing outward from the colon wall is called a diverticulum.  More than one bulging sac is referred to as diverticula.  Diverticula can occur throughout the colon, but most are common near the end of the left colon.  This is referred to as the sigmoid colon.  The condition of having these diverticula in the colon is called diverticulosis.

A patient with diverticulosis may have few, if any, symptoms.  When a diverticulum becomes infected and ruptures, the condition is called diverticulitis.  A patient suffering from diverticulitis experiences abdominal pain and tenderness, often accompanied by fever.  Bleeding which originates from a diverticulum is called diverticulitis bleeding.  Diverticular disease is common in the Western areas of the world, but is extremely rare in areas such as Asia and Africa.  Diverticular disease increases with age and is uncommon before the age of forty.  Most patients with diverticulitis develop bleeding, infection, constipation, abdominal cramps, and occasionally, colon obstruction.

The treatment needed for diverticulitis depends on how bad the symptoms are and whether an infection exists.  In general there are a small percentage of people whose condition will move from diverticulosis to diverticulitis.  This disease is generally seen in almost half of all Americans over the age of 60, but it is diagnosed to a lesser degree to many who are in their 40's.  The problem seems to increase with age as the weak areas of the colon continue to balloon out and result in pockets. Ballooning is caused by pressure such as exertion when a person is constipated by lack of fiber in their diet or because of certain medications.  It has also been attributed to some gallbladder surgeries that have positioned the gall duct to drip directly into the intestines after the gallbladder has been removed.

It is very possible to minimize the effects of the diverticulitis in those who have already developed the condition.  Choosing to convert to a diet which is aimed to control diverticulitis later in life can have significant health benefits.  The recommended amount of fiber everyone needs to maintain a healthy colon is generally between 20 and 35 grams of fiber every day.  Adding foods like baked beans, brown rice, bran, oats, pears, and squash can easily provide the necessary fiber for anyone.  There are also many supplemental products that can be ingested which offer a valuable amount of fiber that is part of a diverticulitis diet treatment.  For patients who already have developed colon problems, there are also foods that should be restricted from the typical diet in order to avoid problems.  This disease can be managed in many ways, diet being one of the easiest.

Most people who suffer from diverticulosis do not have any discomfort or symptoms, however, symptoms may include mild cramps, bloating, and constipation.  Other diseases, such as irritable bowel syndrome, and ulcers cause similar problems.  These symptoms are not indicative of diverticulosis.  The differential diagnosis of diverticulosis includes colon cancer, inflammatory bowel disease, colitis, and irritable bowel syndrome.  It also includes a number of urological and gynecological processes.  Bleeding from the rectum is also common.  Patients are commonly studied with a CT scan, but also barium enema and colonoscopy tests.

What Is Diverticulitis?

Small pouches along the wall of the colon are called diverticula. When these pouches become inflamed, the condition is called, diverticulitis.  Diverticula’s commonly occur in the sigmoid colon, which is the S-shaped segment of the colon in the left lower part of the abdomen. The section of your abdomen that is nearest to your left hand. Approximately half of all Americans age 60 to 80 have diverticula in their colon. When individuals reach 80 years of age, they usually have diverticulosis.

A major contributing factor for diverticula forming is the elevated pressure within the colon and age. Age, is a factor because as we age our colon walls become weakened, making them more susceptible to the formation of diverticula. The pressure inside the colon rises when we are constipated and we push down in order to pass small, hard bits of stool.

Individuals with diverticulosis rarely know they have the condition because there are usually few or no symptoms of the condition. The few that do have symptoms may experience abdominal cramping and bloating.

The condition, diverticulitis can be potentially serious. The individual may feel pain in the left lower abdomen, may experience a fever, nausea, even vomiting. They may have bouts of constipation with the occasional diarrhea and the occurrence of frequent urination. The condition becomes serious when perforation of the colon, or peritonitis occurs.

Complications:

Complications of diverticulitis also include bleeding, and blockages. Treatment can prevent these complications from progressing and causing more serious illness.

Bleeding from diverticula is a rare complication and is noticeable by blood appearing in the toilet or in your stool. Bleeding can be severe, or it can be mild. The bleeding can stop by itself without requiring treatment. If the bleeding does not stop on its own, than surgery may be required.

Diverticulitis can lead to an abscess, perforation or peritonitis. The abscess forms if the diverticulitis does not clear up. An abscess is an infected area (diverticulitis) that swells and destroys surrounding tissue. The doctor will insert a needle with a small tube in order to drain the abscess. This procedure to drain an abscess is called “percutaneous catheter drainage”. Surgery to remove any destroyed tissue or to clean up the abscess may be required. If the infection spreads beyond the colon and into the abdominal cavity is called peritonitis. The presence of peritonitis requires immediate surgery. During this surgery the abdominal cavity will be cleaned and the affected part of the colon is removed.

Prevention, Diagnosis and Treatment:

You can prevent diverticulitis by avoiding the development of diverticula. There is little you can do about the aging process, but you can eat a healthy diet that contains plenty of fiber. A diet that is high in fiber will help to keep the bowels functioning properly and moving quickly which keeps the pressure within the colon within normal limits, which stops the formation of diverticula.

If the individual has barium x-rays of the colon or a sigmoidoscopy or a colonoscopy, the condition of diverticulitis can be diagnosed.

The doctor will then devise a treatment plan that will control the inflammation and the infection associated with the condition.

Surgery for Diverticulitis

Diverticulitis develops when bacteria becomes trapped in pouches called diverticula that have formed along the wall of the large intestine.  This leads to an infection.  The bacteria grow and cause inflammation and pressure which may lead to a small tear in the wall of the intestine.  The infection, called peritonitis, may develop if infection spills into the abdominal cavity.  The reason diverticula form in the wall of the large intestine is not completely understood.  Typically, a diet with adequate fiber produces stool that is bulky and can easily move throughout the colon.  A diet low in fiber requires the colon to exert more pressure than usual to move small and hard stools.  A low fiber diet can also increase the time the stool remains in the bowel, which adds to the high pressure. 

Surgery for diverticulitis involves removing the diseased part of the colon.  A doctor may recommend surgery for diverticulitis if there is a stricture, or a partially blocked colon or a narrow spot in the colon.  Repeated attacks of diverticulitis may indicate that surgery to remove the diseased part of the colon due to two or more severe attacks.  High risk of complications is a good indicator that surgery is required.  Repeated problems with bleeding from the colon or an abnormal opening, or fistula that has formed between the colon and an organ near it, along with possible signs of cancer may indicate surgery is needed.  Surgery for diverticulitis, in which the infected part of the colon is removed, may be required. 

Overall, less than 10% of people with diverticulitis require surgery.  Surgical treatment involves removing the diseased part of the large intestine, called a partial colostomy, and reconnecting the remaining parts.  Depending on both the severity and nature of the symptoms, more than one surgery may be required to correct the problem.  When multiple surgeries are required, the person usually has a colostomy between surgeries.  A colostomy is a surgical procedure in which the upper portion of the intestine is sewn to an opening made in the skin of the abdomen.  Stool passes out of the body through this opening and into a disposable bag.  The colostomy is then removed and the intestine is reconnected at a later date. 

No screening is available at this time for diverticulitis.  Starting at age 40, a procedure called a flexible sigmoidoscopy may be recommended every 3 to 5 years or a colonoscopy every 10 years as a screening exam for cancers of the colon and rectum.  Both flexible sigmoidoscopy and colonoscopy involve using a flexible tube with a lighted viewing instrument to see inside the large intestine.  These exams are often able to reveal diverticula if they are present.  Treatment after recovery from an attack of diverticulitis is aimed at preventing another attack.  This treatment may include getting plenty of fluids daily, gradually increasing the amount of fiber in the diet through fruits, vegetables, wheat bran, and the regular use of a fiber supplement.  It is also highly recommended that regular doctor visits are conducted to monitor the condition.