Colon Diverticulitis

What is Colon Diverticulitis?

Over the recent years, there’s been a rise in the number of people suffering from diverticulitis, a condition which is becoming a serious health issue, particularly in Western countries. In the United States alone, almost 200,000 hospital visits and $2.2 billion in medical expenses each year can be linked to acute diverticulitis. This disease is more common as people get older, but it’s not just restricted to the elderly – younger adults can get it, too. There was even a belief at one point that younger patients, particularly men, were more likely to have a severe form of diverticulitis, with higher rates of complications and reoccurrences.

However, recent research has questioned this belief. Both environmental factors and genetic predispositions can contribute to the development of diverticular disease, but we still don’t know enough about many of these factors. The good news is that most people with diverticulitis can be effectively treated outside of a hospital setting using oral antibiotics and some temporary changes to their diet. When it comes to more invasive treatment like a sigmoid colectomy — a type of surgery to remove part of the colon — after recovering from uncomplicated diverticulitis, the decision can be controversial and needs to be considered on an individual basis. In severe cases of diverticulitis, surgical treatment often becomes the recommended course of action.

What Causes Colon Diverticulitis?

Diverticular disease begins when the inner lining of the colon wall bulges outward, creating tiny pouches. This condition can lead to diverticulitis, an inflammation of these pouches. The common explanation for this is an increase in bacteria due to fecal matter blocking the base of the pouch, which may cause tiny breaks.

However, this theory has been under debate recently as some research studies have shown that simple cases of diverticulitis can get better without antibiotics in certain situations.

Risk Factors and Frequency for Colon Diverticulitis

Diverticulosis of the colon, a condition where small bulges or pockets develop in the digestive tract, is common, especially in western countries, and its occurrence increases with age. People over the age of sixty are most affected, with over 50% of them having diverticulosis, and by the age of eighty, this percentage goes up to 70%. However, despite its high occurrence, only about 4% of people will develop diverticulitis, a condition where these pockets become inflamed or infected, in their lifetime.

The location of these pockets in the colon differs based on population demographics. In Western countries, they are most commonly found in the lower part of the colon, known as the sigmoid colon. However, in Asian populations, the pockets are more commonly found in the right colon. Lifestyle factors such as diet play a significant role in the development of diverticulosis, but research has shown that there is also a genetic predisposition for it.

There are different factors thought to affect the development of diverticulosis, although some still spark debate. Some studies suggest a high-fiber diet can help prevent diverticulosis, and both the American Gastroenterology Association and the American Society of Colon and Rectal Surgeons recommend a high-fiber diet for people with a history of diverticulitis to reduce the risk of future episodes. However, the authenticity of this claim is still under examination.

In the past, people with diverticular disease were often advised to avoid eating nuts, seeds, and popcorn, but recent studies have shown that these foods do not increase the risk of diverticulitis. Certain habits and foods, including obesity, smoking, alcohol use, and frequent consumption of red meats, particularly beef and lamb, can increase the risk of developing this disease. Some medications, such as NSAIDs, ASA, and acetaminophen could also increase the risk of developing severe diverticulitis.

On the other hand, certain factors are believed to lessen the risk of developing diverticulitis:

• Vigorous exercise, like running, can reduce the risk by 25%.
• Light activities, such as walking have lesser benefit.
• Taking statin medications.
• Maintaining a normal weight.
• Avoiding smoking.

Signs and Symptoms of Colon Diverticulitis

Diverticulosis is a condition which often does not cause any noticeable symptoms in most people. It’s usually discovered by chance during routine investigations like a colonoscopy or other radiological procedures. However, when diverticulosis becomes inflamed, it evolves into a condition known as diverticulitis. This can lead to a variety of symptoms such as:

• A fever
• Pain in the lower left part of the abdomen
• Changes in bowel habits
• Nausea
• Vomiting
• Constipation
• An increase in gas and bloating

Patients with diverticulitis may also experience complications like the formation of an abscess, a hole in the colon, or abnormal connections between organs known as fistulas. When diverticulitis becomes severe or complicated, patients may also show signs of infection, such as a high white blood cell count and elevated markers that signify inflammation. Severe cases can manifest in symptoms like a tender, bloated belly, the absence of the sounds made by your intestines (bowel sounds), or symptoms related to fistulas like the presence of fecal matter or air in your urine. They indicate the possible development of an abnormal connection between the colon and bladder, known as a colovesical fistula.

Testing for Colon Diverticulitis

If your doctor suspects you have acute diverticulitis, they will consider your medical history, perform a physical exam, and review your lab results. If these factors hint towards diverticulitis, you will be required to undergo imaging tests for a firm diagnosis.

There are a few different types of imaging tests you could undergo, like ultrasound and barium enema, which are used to detect any abnormalities in your digestive system. However, the most preferred technique is a CT scan of your abdomen and pelvis with special dyes, which you take orally and intravenously. This method is highly reliable with 98% sensitivity which means it can accurately identify patients with diverticulitis. But before you’re given the dye, your kidney function needs to be checked to ensure it’s safe.

The typical findings on a CT scan in a diverticulitis case include thickening of the colon wall and areas appearing like strands of fat. The scan can also spot severe complications like the formation of an abnormal connection between different parts of your intestines (fistula), abscesses, and free air within your abdominal cavity.

Your doctor may use a system called the Hinchey Classification to determine the severity of your condition. This system helps to guide the best treatment option for you.

In most cases, patients with minor diverticulitis (stages 1a and 1b on the Hinchey scale) can be managed without surgery. Those in stage 2 might need a drain inserted into the affected area followed by a later surgery to remove this part of the colon. However, if you’re categorized as stage 3 or 4, you’re likely going to need immediate surgery.

It’s also worth noting, if a urinalysis shows red or white blood cells, the doctor might suspect a fistula forming between your colon and bladder. Additionally, if you’re a woman who’s able to conceive and you’re experiencing abdominal pain, a pregnancy test would be necessary to exclude the possibility of an ectopic pregnancy.

Treatment Options for Colon Diverticulitis

Treating a simple case of diverticulitis usually involves oral or intravenous antibiotics, controlling the pain, staying hydrated, and limiting what is eaten and drunk. Traditionally, antibiotics are utilized in treating diverticulitis, yet, decisions about the specific antibiotic to use, how long to use it for, and how it should be given, are still areas of debate. In most instances, simple diverticulitis can be managed successfully without hospitalization. Antibiotics such as ciprofloxacin and metronidazole or amoxicillin-clavulanate are taken orally for 7 to 10 days. During this time, patients are advised to limit their food intake until their pain goes away.

Patients who have a fever, weak immune system, difficulty staying hydrated, or multiple other health conditions may require hospital admission for treatment with non-oral antibiotics. As their symptoms get better, patients are gradually reintroduced solid foods and are given oral antibiotics. If a patient does not improve on non-oral antibiotics, or their condition worsens, a repeat evaluation with a CT scan is recommended to check for potential complications.

After recovering from an episode of diverticulitis, a colonoscopy is typically advised 6 to 8 weeks later, especially if the patient hasn’t had one in the past 2 to 3 years.

In the past, a surgical procedure called elective sigmoid colectomy was done after a patient’s second instance of simple diverticulitis. However, more recent findings have shown that this approach isn’t beneficial. Firstly, the reported rates of recurrence are less than previously believed, ranging from 13 to 23%. Secondly, the chance of the disease coming back in a complicated form that may require an artificial opening for waste removal (a stoma) is also low, at around 6%. Therefore, treatment decisions should be personalized, based on factors such as the number, severity, and frequency of diverticulitis episodes, persistent symptoms after an episode of diverticulitis, and the patient’s immune status. Age, other health conditions, and lifestyle should also be considered. In younger patients with this condition, treatment should be the same as for older patients.

In the case of performing an elective sigmoid colectomy for diverticulitis, it’s crucial that the entire sigmoid colon is removed and that the joins between the ends of the bowel are healthy, well-supplied with blood, and free to move without strain.

Only about 1% of patients experiencing an acute episode of diverticulitis will need surgery. Patients who show signs of peritonitis may need emergency surgery. If it is confirmed during surgery that the diverticulitis has developed a hole, the standard operation is a Hartmann procedure. This operation involves removing the sigmoid colon, creating a pouch from the remaining rectum, and creating an end colostomy to allow waste to leave the body. The benefit of this procedure is that it removes the risk of the joined parts of the bowel leaking. Patients will generally have their colostomy reversed within 3 to 6 months. However, due to factors such as old age and associated health conditions, nearly 30% of patients who undergo a Hartmann procedure never have their colostomy reversed.

Patients with Hinchey 3 and 4 diseases have a second surgical option involving a primary colorectal junction with a bypassing small intestine waste opening. Preliminary reviews of this type of surgery show a decrease in the overall death rate when a primary junction is performed. However, we still await scientific studies comparing this procedure to the Hartmann procedure.

Acute colonic diverticulitis should be managed in stages, with patients meeting certain criteria (including signs of more complex diverticulitis, systemic infection, abnormal vital signs, white blood cell count anomalies, C-reactive protein level above 15 mg/dl, or several comorbidities such as diabetes or recent heart attacks) admitted for inpatient management. This involves intravenous antibiotics, hydration, pain control, and complete bowel rest.

In patients who do not meet these criteria, they can be treated as outpatients with pain control and a liquid diet. However, the response to this conservative treatment should be assessed again after the first 72 hours. Those that have not improved should be admitted to receive treatment as an inpatient. If all the symptoms are gone within six weeks of the starting episode, a planned colonoscopy should be scheduled.

Patients who do not meet any of the mentioned criteria can be treated as outpatients with pain control and a liquid diet. However, improvements should be assessed in two to three days. If no improvement is seen within three days, inpatient treatment should be started, involving intravenous antibiotics, hydration, pain management, and complete bowel rest.

During inpatient treatment, any complications like a tear in the bowel, blockage, or abnormal connection formation need to be checked. If detect any of these circumstances, surgical referral should be considered. In the absence of these issues, a drainable abscess of 4 cm or larger should be drained through the skin. If the abscess is less than 4 cm or no improvement is seen within three days, a further clinical assessment should be carried out.

What else can Colon Diverticulitis be?

Diverticulitis is a condition that can affect any part of the colon. This means that the symptoms of diverticulitis can vary greatly depending on the specific area of the colon that’s involved. For example, if it happens in the right side of the colon, symptoms might look like that of appendicitis. Similarly, when diverticula affect the middle part of the colon, it could mimic the symptoms of stomach ulcers, pancreatitis, or gallbladder inflammation.

Because of its varying symptoms, there are many other conditions that doctors need to rule out before confirming a diagnosis of diverticulitis. These may include:

• Stomach inflammation (gastritis)
• Pancreatitis (inflammation of the pancreas)
• Appendicitis (inflammation of the appendix)
• Gallbladder inflammation (cholecystitis)
• Kidney infection (pyelonephritis)
• Bile duct infection (cholangitis)
• Reduced blood flow to gut tissues (mesenteric ischemia)
• Severe constipation
• Chronic digestive disorders such as irritable bowel disease and syndrome
• Pelvic inflammation
• Ovarian cyst
• Abnormal pregnancy, outside the uterus (ectopic pregnancy)

What to expect with Colon Diverticulitis

The future health of patients is influenced by how severe their sickness is and whether they have any accompanying complications. Those with weakened immune systems face more serious health risks and a higher likelihood of death due to sigmoid diverticulitis.

After the first occurrence of acute diverticulitis, the chances of it happening again within five years is about 20%. Several studies have shown a strong connection between a higher body mass index (BMI) and the risk of developing diverticulitis.

Possible Complications When Diagnosed with Colon Diverticulitis

Diverticulitis can lead to several complications, which can sometimes be more severe, especially for people with weakened immune systems. For example, individuals with HIV or those taking medicine to suppress their immune response are more vulnerable to an intestinal tear also known as perforation. Possible complications of diverticulitis include:

• Formation of an abscess (the most common complication)
• Perforation (tear) in the intestine
• Formation of an abnormal connection (fistula) in the intestine
• Blockage (obstruction) of the intestine
• Peritonitis, a widespread infection of the lining of the abdomen
• Stricture disease, which involves the narrowing of the intestine
• Sepsis, a severe infection that can spread throughout the body

Preventing Colon Diverticulitis

To avoid their condition from coming back, patients are recommended to eat a lot of fiber-rich foods, drink 6 to 8 glasses of water each day, engage in physical activity regularly, keep an eye on any changes in their toilet habits, and use a medicine to soften their stool if they have difficulty in passing a bowel movement due to constipation.