Diverticula of the colon are very common in western countries and we talk about a diverticulosis when many such diverticula are present in the colon. However, as long as these diverticula do not cause any symptoms, they usually do not require any treatment. Eighty percent of individuals who have diverticula of their colon never develop symptoms. Only if diverticula become symptomatic we are talking about “diverticular disease”.
When diverticula of the colon become inflamed, we are talking about a “diverticulitis”, that can be associated with severe abdominal pain and might entail dangerous complications, such as abscess formation or perforation. In these causes emergency surgery might be necessary.
If you suffer from symptoms from diverticula, please do not hesitate to contact us. We are happy to discuss the situation and potential treatment options with you.
Symptoms such as lower abdominal pain, fever, changes of bowel habits, etc. might be caused by diverticulitis. To identify the cause of this symptoms, further investigations might be necessary. The palpation of the abdomen might reveal pain and hardening in the lower abdomen. Inflammatory signs might be elevated in blood tests. Imaging by ultrasound or CT scan can help to identify the extent of the inflammation. Colonoscopy is usually not indicated during the phase of an acute inflammation.
The treatment depends in large part on the stage of the disease. While simple and localized inflammation can in most cases be successfully treated by bowel rest and medication, severe and complicated disease e.g. entailing abscesses, fistulas or perforation, usually requires surgical treatment and in some cases even emergency surgery.
Ninety percent of colonic diverticula are located in the last, S-shaped part of the colon, the so-called sigmoid colon. Different to other parts of the intestine, the architecture of the wall of the sigmoid colon shows small gaps for blood vessels in the muscle layer, that allow diverticula to develop and are the reason why the majority of diverticula are found in the sigmoid colon and not in other parts of the colon.
The older people get, the more likely they are to develop diverticula with people beyond the age of 70, carrying diverticula in more that 50% of the cases. However, we observe a growing number of young people who develop not only diverticula, but also complications of these diverticula such as diverticulitis. Factors promoting the development of diverticula are obesity, low-carb diet, lack of exercise, etc., and these circumstances are becoming more and more common in our society.
The sole presence of diverticula, that are frequently identified during colonoscopies, is not a disease and we are only talking of a “diverticulosis” as long as diverticula are not causing any symptoms. However, these diverticula do not go away anymore and can eventually cause symptoms. If this happens, we are talking about “diverticular disease”. To avoid their development and to reduce the risk of diverticula becoming symptomatic, individuals should eat a high-fiber diet, exercise frequently, and keep their body weight in the normal range. This also helps to prevent the development of other diseases such as colorectal cancer, hypertension, and diabetes, etc…
While many people carry diverticula in their sigmoid colon, only 10-15% of these individuals develop symptoms over time. The most common problem that occurs, is an inflammation of one or several diverticula and the adjacent piece of the colon. This inflammation can extend into the surrounding of the colon and the extent and degree of this inflammation usually determines the necessary treatment.
Recurrent and even minor inflammation can cause a scaring of the bowel leading to a narrowing and stenosis of the bowel lumen, that can hamper to passage of stool through the bowel and lead to obstruction and constipation. If medical regulation of bowel movements fails, surgical intervention might be indicated.
As diverticula protrude through small gaps in the muscular layer of the colon, through which also blood vessels find their way through the bowel wall, diverticula can also cause severe bleedings, with significant perianal loss of blood. If such a bleeding cannot be stopped during endoscopy, surgery might be required in rare case.
The complaints usually depend on the degree of inflammation. As the sigmoid colon is located in the left lower quadrant of the abdomen, this is where the pain most frequently occurs. Most patients also report of fever or shivering and some patients observe changes in their bowel habits that can be obstipation as well as diarrhea. When diverticula rupture, a perforation can occur with stool and bacteria getting into the abdominal cavity leading to the development of a so-called peritonitis that is usually accompanied by massive and diffuse abdominal pain, fever, and sickness and that requires immediate presentation to a hospital followed by surgical intervention.
While one or two decades ago patients with diverticulitis were usually operated after the first or second attack, we nowadays become much more reluctant with the indication for surgery for the treatment of diverticulitis. The reason is, that we learned that not all patients who develop one or two uncomplicated attacks of a diverticulitis, also develop further attacks, but that a large proportion of these patients will not experience further attacks during the rest of their lives. Furthermore, in contrast to the general thinking, it has been demonstrated, that the risk of severe complications such as a free perforation of the bowel with peritonitis and the need for emergency surgery, appears not to increase but rather to decrease with the number attacks, as long as these are so-called “uncomplicated attacks”. Therefore, nowadays, the indication for patients to undergo surgery for recurrent diverticulitis, is in most cases not based on the number of attacks patients develop, but rather on the degree of inflammation and on how much patients suffer from the disease.
The recent guideline for the treatment of diverticulitis distinguishes between “uncomplicated” and “complicated” disease. The inflammation is limited to the bowel wall in patients with “uncomplicated” diverticulitis. This situation can usually be successfully treated with bowel rest, pain medication, and antibiotics and rarely requires surgical intervention. In contrast, “complicated” diverticulitis is usually associated with a at least temporary leak of the bowel wall, leading to a spill of bacteria into the surrounding of the bowel, that can lead to abscess formation or peritonitis. In these cases, surgery should be considered. In patients with a localized abscess it can be useful to drain the abscess, e.g. by a CT-guided drainage, and to minimize the inflammation by the use of antibiotics before undergoing resection of the affected piece of colon. Differently, emergency surgery is necessary in cases with free perforation and peritonitis that can lead to a life-threatening situation.
The quality of life of patients who suffer from recurrent attacks of a diverticulitis, leading to pain, use of antibiotics, sick leave, and admission to a hospital can be seriously impaired and patients often suffer from the insecurity when they are planning their private and work life. In these cases, surgery can be considered on an individual basis balancing the restrictions patients experience due to the disease against the relatively low risk of the surgical procedure. This is particularly the case when patients do not respond to medical treatment anymore and the symptom-free intervals become shorter and shorter. We are glad to give you our advice in this difficult situation.
During surgery, not only the inflamed diverticula are removed. In fact, the operation comprises the removal of the entire sigmoid colon, as due to the anatomical properties of this piece of bowel, this entire segment has to be removed to prevent the recurrence of the disease later on after the operation. The procedure is usually carried out by minimal invasive, laparoscopic surgery with a discharge about five to seven days after the operation.