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.

Dear Doctor: A friend recently told me he was feeling…