Current management of Diverticulitis

Diverticulosis is a common finding in patients undergoing screening colonoscopy. A question frequently asked following this procedure is “what is the difference between diverticulosis and diverticulitis and what is the treatment?”

In layman’s term, diverticulosis is a condition characterized by the abnormal formation of sacs (in medical parlance, diverticulum or diverticula [plural]) or pockets in the walls of the colon. The sigmoid colon, the portion of the large intestine above the rectum, is the most common location of this abnormality. This affliction is often seen in the seventh decade of life or older, although, in my practice, I have seen an increasing number of younger people with worse features of this disease than some septuagenarians.

What causes diverticulosis? Basically, most studies aver that this is an acquired condition. A widely held view is that increasing intra-colonic pressure due to inadequate fiber in the diet is the underlying culprit. An interesting observation is that this problem is prevalent in highly industrialized nations like the USA, because the diet is lacking in vegetable fibers; in countries where the diet is vegetable based with little to no meat all, the incidence of diverticulosis is almost unknown.

Then, when people from these “vegetable-based cultures” such as Africa come to this country and subsist on a Western diet, they readily develop this abnormality. Another notable observation is that when the amount of dietary fibers in the American or Western diet decreased during the last century, the amount of white flour and refined sugar increased.

Most diverticular diseases are diagnosed when they become inflamed, the condition called diverticulitis. In the last 10 years, this resulted in nearly 300,000 U.S. hospital admissions, the equivalent of $1.8 billion of annual direct medical costs, according to latest reports.

The most common presentation of the mild form of acute diverticulitis is left lower abdominal pain, not associated with nausea, vomiting or fever; this can be treated conservatively without hospitalization. More severe abdominal pain, associated with severe abdominal tenderness, peritonitis, bleeding and fever may require hospitalization with intravenous fluids, antibiotics and other supportive medical treatment. During hospitalization, the patient is worked up for possible perforation and abdominal contamination, which are indications for immediate surgical intervention.

In prior years, diverticulitis, whether mild or severe, was considered a surgical disease. Patients were advised immediate surgical intervention because of the fear of complications. This concept has been rendered obsolete by the current better understanding of the disease process.

Space limitation would not allow comprehensive review of the modern treatment of diverticulitis, but some current information should be highlighted. Generally known risk factors such as smoking, diabetes and sedentary lifestyles are also predisposing factors in the development of diverticulitis; the use of nonsteroidal anti-inflammatory drugs can lead to perforation; that diverticulitis is not associated with corn, popcorn or nuts, instead, the latter lower the risk of diverticulitis. Prolonged use of antibiotics is not indicated in the treatment of non-complicated diverticulitis; it does not prevent pain or future attacks.

Some studies have shown that medications used for other types of inflammatory bowel diseases work effectively in controlling diverticular pain.

The role of surgery in managing diverticulitis, apart from the true emergencies, has significantly changed. Essentially, modern scientific reviews conclude that the decision to perform elective colon surgery should be individualized and should be based “on patient characteristics and presentation.” The old advice of routinely resecting part of the colon to prevent future attacks is not backed by credible scientific study.

Reference: Surgery for Diverticulitis in the 21st Century A Systematic Review ONLINE FIRST. Scott E. Regenbogen, MD, MPH1; Karin M. Hardiman, MD, PhD1; Samantha Hendren, MD, MPH1; Arden M. Morris, MD, MPH1 JAMA Surg. Published online Jan. 15, 2014.

Dr. Cabasares is a board certified general surgeon and Fellow of the American College of Surgeons; he practices in Perry.

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