Diverticulitis

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If you have diverticulosis, you know how debilitating diverticulitis flare-ups can be. To prevent these, your doctor may suggest that you eat more fiber, drink plenty of fluids, and exercise regularly.

When lifestyle changes aren't enough, you have other options to getting you back on the road to health.

Learn more about diverticulum, what the symptoms are, your surgical options and more.

What is diverticulitis?

Diverticulosis is the medical name for the presence of diverticulum, or small pouches formed in the colon wall. The cause for development of these is not well understood. It is possible the development is a side effect of having too low amount of fiber in your diet. Without fiber to add bulk to the stool, the colon has to work harder than normal to push the stool forward. The pressure from this may cause pouches to form in weak spots along the colon. There also seems to be a genetic component, so it can run in families.

When the diverticulum are present but not causing problems, we call it Diverticulosis. We find diverticulum when we conduct a test for other reasons, like a colonoscopy or barium enema. Many people with diverticulosis have no symptoms. They will remain symptom free for the rest of their lives.

Diverticulum

Diverticulitis happens when the diverticulum become inflamed. Particles of stool or undigested food become stuck in these pouches. This creates both inflammation and infection in the wall of the colon. The infection is due in part to the bacteria that naturally live in the colon. The inflammation causes increased pressure in the diverticulum and discomfort for you.

In severe cases, the pressure can cause the diverticulum to burst. Then stool and bacteria flood your lower abdomen causing a severe wide-spread infection.

Symptoms of diverticulitis

The symptoms of diverticulitis depend upon the degree of inflammation and infection present. Symptoms can include:

Abdominal pain, many times in the lower abdomen, more often on the left side, but can be present on the right side as well
Fever and chills
Diarrhea or constipation, can have blood or mucous in the stool
Nausea with decreased appetite, sometimes with vomiting
Blood from the rectum
Pain in the pelvis area with urination (this is due to inflammation around your bladder and its proximity to the colon)

You should seek medical attention if you have any of these symptoms. Diverticulitis can progress into a severe, wide-spread infection if left untreated.

Testing for diverticulitis

Your doctor will assess your symptoms and do an examination of your abdomen, as well as the rest of your body. You will need tests to determine if you have diverticulitis.

Blood tests to look for signs of infection, check your kidney and liver functions
Urine test to look for infection in the urinary tract
A CT scan, or an image of your abdominal organs

Complications associated with diverticulitis

Simple diverticulitis accounts for 75 percent of cases. Treatments take place at home using antibiotics and lifestyle changes.

Complicated diverticulitis is more severe and accounts for 25 percent of cases. In most cases, you will need hospitalization and surgery. Complications associated with diverticulitis can include the following:

Abscess — This is a localized collection of infection next to the inflamed colon. This is usually caused by a “microperforation,” or a very small hole in the diverticulum. The hole allows bacteria to escape from the colon into the abdomen. The body is able to contain the infection to a small area by “walling off” the pus.
Recurrence — After you have one episode of diverticulitis, you are at higher risk of having another. Each flare up can become more severe. About 1/3 of patients that have one episode of diverticulitis will have future episode(s).
Fistula — This is a hole created between two areas not normally connected. For example, a hole forms between the colon and the bladder.
Obstruction — A blockage of the colon is due to inflammation of the colon. The colon wall thickens and stool is not able to pass through.
Peritonitis — If your colon develops a hole, the contents of your intestines spill into your abdomen. This wide-spread infection of the abdominal cavity has the diagnosis of peritonitis.
Sepsis — An overwhelming body-wide infection that can lead to failure of many organs.
Diverticular bleeding — When a small artery located within the diverticulum breaks through the colon lining and bleeds into the colon. This can happen with diverticulosis and diverticulitis. Diverticular bleeding usually causes painless bleeding from the rectum. In about 50 percent of cases, the person will see maroon or bright red blood with bowel movements. Bleeding with bowel movements is not normal and you should immediately seek medical attention. Most cases of diverticular bleeding resolve on their own. Some people will need further testing or treatment to stop bleeding. Testing may include a colonoscopy, angiography (blocking off the bleeding artery) or surgery.

Treatment for diverticulitis

Treatment of diverticulitis depends upon how severe your symptoms and disease are. People with diverticulosis who do not have symptoms do not need treatment.

Increase fiber to add bulk to the stool — Fiber can help to bulk up your stool. A high-fiber diet might prevent new diverticula, diverticulitis or diverticular bleeding. Fiber has not proven to prevent these conditions or get rid of current diverticuli. Fruits and vegetables are a good source of fiber. You calculate fiber content of packaged foods by reading the nutrition label.
Take fiber supplements — You can take fiber supplements like Metamucil, Citrucel or Benefiber to bulk up your stool.
Seeds and nuts — In the past we advised diverticulitis patients to avoid whole pieces of fiber, like seeds, corn and nuts. There was concern that these foods could cause an episode of diverticulitis. This belief is completely unproven. So we no longer recommend avoiding these high fiber foods.

Home treatment

Patients with mild, uncomplicated diverticulitis may manage at home by:

Sticking with a liquid diet to allow the colon to rest and allow the inflammation to heal
Taking oral antibiotics to treat the infection.

If you have a mild form of this disease, you might get better with this alone. But you might need antibiotics for your treatment. In some cases, your infection will return when you stop the antibiotics.

A small percentage of patients will continue to their disease progress, despite proper treatment. To find relief, you may need hospitalization and more aggressive treatment.

If you are being treated for diverticulitis and you develop one or more of the following signs or symptoms, seek immediate medical attention:

Temperature >100.1ºF (38ºC)
Worsening or severe abdominal pain
An inability to tolerate fluids by mouth

Hospital treatment

If you have moderate to severe symptoms, with any of the below complications, you will likely need hospitalization for more aggressive treatment.

Temperature >100.1ºF (38ºC)
Worsening or severe abdominal pain
An inability to tolerate fluids by mouth

During this time, you will not allowed to eat or drink. This allows the colon to rest and heal. We deliver antibiotics, fluids or needed medications through an IV (intravenous) line.

Other treatments depend on the degree of infection you have. We determine your infection degree through:

Blood testing
CT scan, or other imaging studies
Physical examination

If you have an abscess, we attempt to drain it without major surgery. This quick procedure is done under radiology guidance. A small needle and a drainage tube are placed in the abscess to remove and test the infected fluid.

If you have an obstruction in the colon, you will most likely need surgery. During surgery we remove the inflamed segment of colon and unblock it. This relieves the intestines and you can again pass your stool.

You will almost always need emergency surgery if you have either:

Peritonitis or an infection in the abdominal cavity
Sepsis or a severe and wide-spread infection due to a hole in the colon wall

In either case, we remove the perforated part of your colon. Then our care experts clean the infection from your abdominal cavity.

Surgical treatment

If you develop an abdominal infection, you will usually need emergency surgery.

The surgery removes the diseased and ruptured part of the colon. A two-part surgery may be necessary in some cases.

The first surgery involves removal of the diseased colon and creation of a colostomy. A colostomy is an opening in the skin, where the end of the colon is brought out to the outside. You attach a bag on this end to collect the stool (bowel movements) from the intestine. The lower end of the colon is temporarily sewed closed to allow it to heal.

Connecting the ends immediately is unsafe. Connecting them would put that new junction at very high risk of breaking down.

Instead, we allow the colon inflammation to recede and the infection to go away. Approximately three to six months later, we perform a second surgery. This time we 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.

In some non-emergency situations, we remove the diseased area of the colon. Then we reconnect the two ends of the colon in one surgery, without the need for a colostomy.

Click here for more information about colectomy.

Delayed surgery

If you have a complicated form of diverticulitis, you may need a delayed surgery care plan. First, we try to treat the infection and inflammation with antibiotics and bowel rest. Your doctor reserves surgery for only true emergencies, like peritionitis and sepsis.

If your condition permits, we treat you with antibiotics for several weeks, sometimes 6-8 weeks. Then you get surgery to remove the diseased part of the colon several months later. The chance of recurrence is high if you decide not to have surgery).

Waiting before having surgery allows inflammation and infection to heal. Your surgeon will do a 1-stage surgery where he or she removes the diseased part of the colon and reconnect the colon at the same time. Most patients prefer this over the 2-stage surgery with the colostomy.

Your doctor will discuss all known risks and benefits of surgery versus medical management alone.

Delayed surgery

In many cases of complicated diverticulitis, the doctor will try to treat the infection and inflammation with antibiotics and bowel rest, and try to reserve surgery for only true emergencies (such as with peritionitis and sepsis). If this is possible, you may be treated with antibiotics for several weeks (sometimes 6-8 weeks), and then surgery to remove the diseased part of the colon will be planned within several months (the chance of recurrence is high if surgery is not done). This allows the inflammation and infection to heal, and will allow the surgeon to do a 1-stage surgery (remove the diseased part of the colon and reconnect the colon at the same time) rather than a 2-stage surgery with the colostomy.

Your doctor will discuss with you the risks and benefits of surgery versus medical management alone.

After diverticulitis resolves

At the end of a diverticulitis episode, you should have the entire length of your colon examined. We usually perform this exam with a colonoscopy. This colon exam gives us the opportunity to determine the extent of your disease. We also can rule out the presence of abnormal lesions such as polyps or cancer.

In rare cases, people can present with what appears to be diverticulitis, but can turn out to be colon cancer.

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Diverticulitis

What is diverticulitis?

Diverticulum

Symptoms of diverticulitis

Testing for diverticulitis

Complications associated with diverticulitis

Treatment for diverticulitis

Delayed surgery

After diverticulitis resolves

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