Little did I know when I experienced my fist episode of diverticulitis years ago that it would later change my health and my life in a dramatic way. Repeated episodes of diverticulitis requiring treatment with multiple antibiotics led to me having recurrent c diff infections. Yet, diverticulitis is not an uncommon problem. Today let’s look at the ins and outs of diverticulitis.
What IS diverticulitis anyway?
Diverticulitis is caused by inflammation and infection of diverticula, or small pockets that sometimes form in thin areas in the walls of the large intestine. (For the record, you can have diverticula in any hollow organ, like your bladder or esophagus, too). These pockets, called diverticula, form when high pressure in the lumen (the inside of the intestine) resulting from slow motility or hard stool cause these little pockets.
When stool hardens in these tiny pockets, it puts pressure on the circulation and causes inflammation. Micro-perforations result causing infection. Ouch!
How common is diverticulitis?
The condition of having these pockets is common. More than 30% of U.S. adults between the ages of 50 and 59 and more than 70% of those older than age 80 have diverticulosis. Diverticulitis is the inflammation of the diverticula, and occurs less often, in 10-25% of people with diverticulosis. 15% of people with diverticulitis will develop an abscess, and 15-30% of them will have recurrent episodes of diverticulitis. I am one of the 15-25%.
What causes diverticulitis?
For years, a low-fiber diet was thought to be the culprit. And for many years, patients were told not to eat seeds or nuts, such as strawberries or sesame seeds or tomatoes. The idea was that they plugged up the diverticula and caused the inflammation but studies have not borne this out, and seeds and nuts are part of a high fiber diet. Now patients are now encouraged to eat high fiber diets to prevent diverticulitis. Patients still come to me and ask about this, but as of 2015, a high roughage diet, which can include nuts and seeds is recommended.
We now know that smoking, obesity, NSAID use (drugs like ibuprofen and naproxen) and a sedentary lifestyle are the causes of diverticulitis. There is a genetic cause as well. I found out only recently that my grandmother, who lived to the ripe old age of 101 years had diverticulitis and for a time had a colostomy that was later reversed (more on that later).
What are the symptoms of diverticulitis?
People with diverticulosis may have no symptoms at all or may develop chronic symptoms, such as constipation or diarrhea, bloating and abdominal pain. When the diverticula become inflamed that is called acute diverticulitis. Symptoms of diverticulitis include severe abdominal pain (usually on the left side), constipation or diarrhea, fever, chills, nausea and vomiting.
How is diverticulitis diagnosed?
Diverticulitis is often treated based upon clinical symptoms. Bloodwork can be done that may show an elevated white blood cell count, indicative of infection, or an elevated marker of inflammation can occur. A CT scan may show signs of colon wall swelling, a sign of inflammation, confirming the diagnosis. Other tests may be done such as a stool test to evaluate diarrhea or a pregnancy test in reproductive females.
How is diverticulitis treated?
Antibiotics used to be a routine treatment. Guidelines from 2015 were updated recently and now recommend that antibiotics be used for immunocompromised patients and on an individual basis, not routinely for simple uncomplicated diverticulitis. Indeed, bowel rest and a clear liquid diet are the mainstay of treatment, and uncomplicated diverticulitis often resolves once such measures are taken. Acetaminophen can be taken for pain, and a heating pad can alleviate some abdominal cramping. Once pain subsides, usually in a few days, diet can be advanced to a full fluid diet (smoothies, cream soups, pudding) and them a “BRAT” diet – some easy to digest low fiber foods. Gradually a normal high fiber diet can be adopted.
What are the complications of diverticulitis?
Some people with diverticulitis may develop a complication, which can include an abscess, fistula (passage between two organs, usually in diverticulitis between the colon and bladder), peritonitis, bowel obstruction or perforation. Intravenous antibiotics may be needed. Occasionally, someone may need a drainage tube, or even surgery.
When does someone need a colostomy?
Folks are often afraid of a colostomy – the dreaded bag that collects poop. Sometimes that is part of the solution, for example, if there is so much inflammation that a simple resection (a connection of healthy bowel segments) can’t be performed. This kind of surgery is sometimes needed for severe complications such as an abscess. Medicine is always looking for less invasive ways to solve problems, and now some folks can simply have a drainage tube instead to allow the infection to drain. Often, if a colostomy is needed, it is later reversed and the bag removed.
When is surgery recommended for recurring diverticulitis?
Most diverticulitis does not require surgery. I was faced with this decision myself, and in fact, the guidelines were upgraded after we’d decided I needed a resection, and before we could get around to doing it. Guidelines used to recommend surgery for more than 2 occurrences of diverticulitis. Now, surgery to prevent recurrence is only recommended when a patient desires an improved quality of life. That is a bit of a squidgy concept. In my case, enduring more recurrences of diverticulitis meant taking more antibiotics and that increases the chance of developing a clostridium difficile infection from the antibiotics again.
Let me say from recent personal experience that even surgery may not prevent the recurrence of diverticulitis. We know we left a few diverticula in my remaining colon – we did not want to take out more colon that necessary. I had an episode of diverticulitis a few weeks ago, the first one since having a sigmoid colon resection, that behaved just like my previous episodes of diverticulitis. This time, it resolved without antibiotic use.
Do probiotics help diverticulitis?
There are some studies suggesting that an impaired microbiome may be associated with diverticula. I don’t think we know yet if that is the cause or the effect of diverticulitis. Guidelines do not recommend taking probiotics, as there simply aren’t high-quality studies that look at this. This is true for c diff infections, too, even though we are seeing “designer probiotics” and microbiome products coming through the FDA-regulated pipeline to treat c diff. I would not be the least bit surprised to find there is a connection to the condition of the microbiome and diverticulitis.
How can I prevent diverticulitis?
Stop smoking. Maintain a normal body weight. Engage in regular moderate physical activity. Eat a high fiber diet, rich in fruits, grains and vegetables. OK, so that is what we should all be doing anyway, but really the benefits of such a lifestyle are really important to many of our body systems. Regular exercise has been shown in studies to provide a moderate decrease in the incidence of diverticulitis. Avoid chronic use of non-aspirin NSAIDS, such as ibuprofen. Taking aspirin for secondary prevention of heart attack is OK.
Diverticulitis is a preventable condition that can cause quite a bit of pain and some serious complications. Recent guidelines have been updated, and studies show a healthy lifestyle is the best prevention.
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Management of acute diverticulitis – American Gastroenterological Association
Update on the management of sigmoid diverticulitis – PMC (nih.gov)
Definition & Facts for Diverticular Disease | NIDDK (nih.gov)