Diverticulitis: challenging but manageable

Dear Doctor: A friend recently told me he was feeling under the
weather due to a flare of his diverticulitis. What is diverticulitis?

Diverticulitis is the process of inflammation of small areas in the
intestines. Occasionally, our intestines can develop small out-pouches
along the length. If one or more of the pouches become inflamed, the
condition is called diverticulitis.

Diverticulosis can occur anywhere along the length of the intestines,
but it is most commonly observed in the intestines that reside in the
left side of the abdomen. There are several reasons for diverticulosis
and, without any additional complications, the condition is considered
benign.

The inflammation can be relatively mild, involving only one or two
areas, to the involvement of extensive areas that can lead to abscesses
and breakdown and rupture of the intestines, a life-threatening
emergency.

Most people with diverticulosis are unaware of it. Diverticulitis, on
the other hand, can have very pronounced symptoms. In some cases,
diverticulosis may cause left-sided abdominal pain and cramping that is
relieved with passing gas or moving one’s bowels. The abdominal cramping
pain can be extreme and severe. Also, one may experience flu-like
symptoms and can even run a fever. Diverticulosis can also produce red
blood in the stool.

Diverticulitis can present as a few isolated attacks, or be
longstanding and chronic, without ever becoming entirely free of
inflammation. With chronic diverticulitis, a blockage of the intestines
can occur.

When this happens, stools can become thin, one can experience
constipation or diarrhea, and stomach cramping and bloating. With
extreme cases of intestinal blockage, one may also experience
excruciating abdominal pain and nausea and vomiting.

Without treatment, diverticulitis can cause pockets of infection that
can rupture into the abdomen and require immediate surgery, scarring
that can lead to intestinal blockage, severe bleeding (that may require a
blood transfusion), and a strange condition called a fistula.

A fistula occurs when an inflamed portion of the intestine
(diverticulitis) touches a neighboring organ and actually forms a
connection to that area. Most commonly, the connection can occur with
the bladder, and when that happens, the kidneys can get infected. Other
less common areas of fistula formation include connections to the vagina
and the skin.

Risk factors

  • Age over 40
  • Overweight
  • Consuming a diet high in red meat
  • Taking NSAIDS or steroids on a regular basis
  • Eating a diet high in saturated fats
  • Low water intake
  • Family history
  • Personal history of polycystic kidney disease

Diagnosis

It is essential to make sure the diagnosis is correct before
embarking on a treatment plan. Many conditions can cause abdominal pain.
Acute appendicitis, fibroids, other intestinal infections, and cancers
of the abdomen (colon and ovarian) are good examples of conditions that
need to be ruled out.

If a patient has a well-documented history of diverticulosis, the diagnosis of diverticulitis may be more straightforward.

Imaging studies can be quite helpful. The imaging study of choice is a
CT scan. If the patient is pregnant, a CT scan is not appropriate due
to the radiation exposure, so an MRI is an acceptable alternative.

Colonoscopy can also aid in the diagnosis of diverticulosis, but in
an acute flare of diverticulitis, colonoscopy should not be used because
the inflamed tissue can easily damage the scope as it travels along the
intestines. Colonoscopy should be done six weeks or longer after the
flare of diverticulitis has subsided. Rarely, exploratory surgery may be
needed to make the correct diagnosis of diverticulitis.

Treatment

The treatment of diverticulitis will depend on the severity of the flare-up.

For mild flare-ups, the treatment may be as simple as staying at home
for a while with bed rest, antibiotics by mouth to address any
infection, a liquid diet while inflammation and healing occur, and a
mild over-the-counter pain reliever, if needed.

If the flare-up of diverticulitis is severe, the affected person may
have to be hospitalized. At that time, IV antibiotics may be
administered with stronger, prescription pain control medications. If
there is an infected pocket, such as an abscess, it may have to be
surgically drained.

If there is a consideration of a perforation of the bowel contents
into the abdomen (peritonitis) or fistula formation, or even a blockage
of the bowels, surgery will be required. In some cases, the diseased
portion of the intestines can be removed and the intestines can be
re-joined without the bad segment. This rejoining of the sections will
allow patients to have regular bowel movements.

In another case, if there are large areas of involvement, the
intestines may be re-routed to empty outside of the body through a
colostomy, and intestinal waste drains into a bag next to the
stomach. In some of these cases, if the inflammation subsides, the
colostomy can be reversed, and the normal intestinal function can be
restored.

If one does have diverticulitis, several lifestyle modifications can be made to minimize episodes. These include:

  • Exercise regularly
  • Maintain a healthy weight
  • Minimize red meat consumption
  • Eat plenty of high-fiber fruits and vegetables
  • Drink plenty of water
  • Minimize saturated fat intake
  • Minimize steroid and NSAID use

Diverticulitis can be a challenging disease. Fortunately, it can be
managed. If you have diverticulitis, talk to your doctor about a regular
visit schedule, what to do with episodes of exacerbation, and ask for
advice on minimizing flare-ups.

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