Diverticulitis Treatment
1. Introduction
Diverticulitis is a common disorder that results from an infection in the colon. Diverticulitis is caused by small pieces of stool that become trapped in the diverticula and become infected. The inflammation associated with diverticulitis is very painful and can lead to severe abdominal tenderness on the lower left side. This condition is caused by a small bulging sac pushing outward on the colon lining, which leads to infection and inflammation of the colon. There is not a specific known cause for diverticulitis; however, it is believed to be caused by a low fiber diet causing increased pressure in the colon and abnormal peristalsis. High amounts of animal fat consumption, particularly red meat, can predispose one to diverticulitis. Animal fats prompt an increase in bile acids, which in turn alters the bacterial composition in the colon. The alterations in bacterial composition cause an increased metabolism of the bile acids, producing deoxycholic acid, which we now know is a highly potent carcinogen and has been linked to colon cancer. This same deoxycholic acid is instrumental in the inflammatory reaction on the colon wall in diverticulitis. Other dietary factors that have been associated with diverticulitis are increased intake of refined sugar and decreased intake of vegetables and fruits. This disease is most common in western countries where low-fiber diets are consumed. Studies have shown that vegetarians have a much lower incidence of diverticulitis.
1.1 Definition of Diverticulitis
Diverticula are small bulging pouches that can form in the lining of the digestive system. They are found most often in the lower part of the large intestine (the colon). The condition of having diverticula is called diverticulosis. During a colonoscopy, it is highly likely that your gastroenterologist will tell you that you have diverticulosis if you are over the age of 40. Usually, diverticulosis is found when a doctor is looking for a cause of unexplained illness with little to no symptoms occurring that the patient knows or feels. Oftentimes, it becomes noticeable that you have diverticulosis when the diverticula are infected, leading to diverticulitis. This is an acute condition which occurs in one out of four people with diverticulosis over a lifetime. Diverticulitis occurs when diverticula tear, resulting in an infection in the surrounding tissue which may cause an assortment of unpleasant symptoms including severe stomach pain, cramping, and change in bowel habits, usually constipation or black stool due to blood in the stool. Other symptoms include fever and rectal bleeding.
Diverticulosis, a condition characterized by the presence of pouches in the colon, typically goes unnoticed because the pockets cause no discomfort and typically do not cause any form of pain or sickness. An estimated 10% of Americans over the age of 40 and half of those over the age of 60 have diverticulosis. When the pouches become infected or inflamed, it leads to a more serious condition known as diverticulitis. This occurs in 10-25 percent of people with diverticulosis and may result in a need for hospitalization and possibly surgery.
1.2 Causes of Diverticulitis
There are many theories on how diverticulitis develops, though there is little evidence to support any one specific idea. The most likely theory is that diverticulosis is a result of a too low amount of fiber in the diet. This then causes the stool to be harder and more difficult to pass, which in turn increases the pressure in the colon. The increased pressure causes the weakened spots in the colon to bulge out and become diverticula. Once the diverticula have formed, it is possible that seeds or husks from fruit and vegetables can block the opening of the diverticula and be the cause of diverticulitis. This theory is based on the fact that diverticulosis is more common in western societies where low fiber diets are consumed. It is also more common in countries where people eat mainly refined food in comparison to places where people eat coarse, unrefined food. This is evidence as countries going through economic development see an increase in diverticulosis to match the increased consumption of low-fiber processed food. Another theory is that the high pressure in the colon causes the mucous lining of the colon to protrude through the weak spots in the colon and form diverticula, but this case would not explain the cause of the mucous lining protruding. Some clinicians believe that it is a neurologic or muscular abnormality in the colon that causes the occurrence of diverticulosis, but again this is purely speculative and there is little evidence to support this view. Other factors that have been studied in relation to the cause of diverticulosis are obesity, smoking, and certain medications, though again, there is little evidence to indicate if or how these factors cause diverticulosis.
2. Medical Treatments
Diverticulitis is an inflammation that occurs in one or more diverticula, which are small pouches that line the colon. This is a painful and uncomfortable condition that can be difficult to self-treat and in some cases require hospitalization. The treatments are broken into two categories: medical and surgical. Over 70% of patients are treated with solely medical interventions, which will be the focus of this essay. Medical treatment is the first step and varies depending on the severity of the disease. Patients may be placed on a clear liquid diet and be prescribed oral antibiotics. If symptoms are severe, hospitalization may be necessary to provide intravenous antibiotics and other interventions. This will be discussed in the following paragraphs. The cornerstone of treating an episode of diverticulitis is antibiotic therapy. This is due to the high likelihood that the inflammation and infection is the result of a microperforation of one of the diverticula in the colon. This causes the fecal matter to escape from the lumen of the colon and into the sterile peritoneal space. The immune system recognizes the leak of fecal material and initiates an inflammatory response to clean up the area. While this is beneficial in ridding the body of the foreign material, the immune system is not designed to "turn off" and it continues the attack, which causes swelling and pain in the abdomen. Antibiotics work by "turning off" the immune system as well as directly killing the bacteria in infected diverticula. The use of antibiotics to treat an uncomplicated case of diverticulitis has been compared to giving an appendicitis patient antibiotics but no surgery. The success rate in both is extremely high.
2.1 Antibiotics
Due to the uncertainty and the undesirable effects of antibiotics, their use is on a case-by-case basis, and it is recommended that they are only used in higher-risk patients.
Whether or not antibiotics actually prevent complications of diverticular disease is uncertain; the trials researching this issue have conflicting results. A Cochrane review in 2012 found that there is no conclusive evidence that antibiotics are effective. An article published in The Lancet in 2017 states that a study of 14,000 patients showed that those who received antibiotics had a 4.5% lower risk of complications, supporting the use of antibiotics for these episodes of diverticulitis.
Current recommendations are to treat such events with oral antibiotics effective against gram-negative organisms. Broad-spectrum antibiotics such as ciprofloxacin and metronidazole have been widely used, but their side effect profiles make them less favorable. Amoxicillin, cephalexin, and co-trimoxazole are considered to be more appropriate due to their effectiveness against the pathogens involved and their lower incidence of side effects.
Diverticulitis is a condition characterized by the inflammation and infection of diverticula, which are bulges in the large intestine. When severe, whether it is accompanied by an abscess, peritonitis, or a fistula, the risk of recurrence or the development of further complications is high. Therefore, the treatment of uncomplicated diverticulitis is aimed at preventing the progression of the disease.
2.2 Pain Management
A variety of issues including reduced bowel motility and partial bowel obstruction can lead to increased pain and bloating with development of diverticulitis, and the consumption of liquid food items can help to avoid these complications. In some severe cases where the bowel has become fully obstructed, a period of bowel rest with nothing by mouth and administration of intravenous fluids will be required.
In severe cases where the patient is unable to eat or drink for an extended period, hospitalization and administration of intravenous fluids and nutrition may be required. This is usually done in a hospital setting where the patient can be monitored until pain and other symptoms are resolved. While there are no definitive studies that have proven a liquid diet is the best course of action during an attack, most physicians will recommend at least a clear liquid diet until symptoms begin to improve.
Pain management is a continuous process during diverticulitis attack. Some patients require no medication, while others need mild analgesics. Codeine, dextropropoxyphene in a low-dose, or NSAIDs are sometimes required. It is extremely important to ensure that the patient's pain is properly managed during the attack, as inadequate pain management can lead to situations where the patient is unable to eat, move, or perform other activities for several days, leading to further complications.
2.3 Dietary Changes
A high fiber diet is the only intervention shown to decrease the recurrence of diverticulitis. There are no plausible mechanisms for dietary fiber to worsen diverticulitis, and it appears safe to recommend in the absence of evidence to the contrary. Increasing dietary fiber can be achieved using fiber supplements, adding wheat bran to foods, or increasing consumption of fiber-rich foods. Of these three strategies, only the use of wheat bran has been specifically studied and shown to be effective. However, wheat bran is not a well-liked food additive, and many patients have difficulty tolerating it. Fiber addition seems to be an intuitive alternative strategy, and its safety and potential benefit may provide some optimism for developing more palatable, fiber-rich foods for these patients. High fiber intake is associated with multiple health benefits and has been shown in some studies to decrease the risk of developing diverticulitis as well. Therefore, patients with diverticulosis should be counseled on the importance of long-term high fiber intake.
Foods with small seeds, such as those found in tomatoes, should be avoided as they can lodge in the diverticula and cause inflammation. This was medical dogma for several decades but has not been supported by epidemiologic data. In fact, several studies have failed to show an association between seed ingestion and diverticulitis. Nuts and popcorn have also been implicated based on the theory that their lack of absorption leads to sharp particles that can irritate the diverticula. Data supporting this also is lacking, and these foods should not be avoided based on the evidence available. High fat intake has been associated with an increased risk of developing diverticulitis in several studies. This has led to the common recommendation to avoid nuts, seeds, and popcorn as they are often high in fat. Whether this is due to the fat itself or the foods that are the source of the fat is unclear, and there has been no differentiation in the types of fat to make recommendations in this area. High red meat consumption has also been linked to an increased risk. As such, red meat should be consumed in moderation.
3. Surgical Options
Indications for surgery The group of patients who should decide to opt for surgical treatment of diverticular disease is a heterogeneous one. The decision to operate is influenced by several factors: patient age, co-morbid medical conditions, continued symptoms complicated diverticulitis, recurrent diverticulitis, and the risks of surgery as they compare to the risks of continued medical treatment. Special circumstances have been clearly outlined where surgery improves long term cost-effective health. Uncomplicated diverticulitis is a relative indication for surgery due to the fact that not all patients who suffer further episodes of diverticulitis develop complications. Elective resection should be considered appropriate therapy for selected patients who have an episode of sigmoid diverticulitis that can be treated without hospital admission. Patients who are immunosuppressed or receiving radiation therapy who have an episode of diverticulitis should be offered elective resection due to the high risk of recurrence. Right-sided diverticulitis is a relative indication for colectomy because disease will likely recur if treatment is by conservative means.
3.1 Indications for Surgery
Recurrent symptoms, complications, and patient preference are all factors that should be taken into account when considering surgery. Patients with severe acute diverticulitis who have purulent or fecal peritonitis have a 6-12% chance of developing further complications of the disease during that hospital admission. Emergency surgery is associated with an increased morbidity and 9-16% mortality in these patients, and a staged approach of an initial percutaneous drainage of the affected area of diverticulitis, followed by interval elective surgery, is often more appropriate. Immunocompromised patients and those with renal insufficiency have an increased mortality if operated on during an acute admission, and a conservative approach in these patients is often appropriate until the episode resolves. Typically, however, surgery is being performed less for the complications of diverticulitis as the morbidity and mortality rates of emergency surgery make this a less favorable option. Elective surgery should be considered for patients following a 2nd episode of complicated diverticulitis as subsequent episodes are associated with a 25-30% major complication rate. At the current time, the best surgical option for patients with an episode of uncomplicated diverticulitis and ongoing symptoms is unclear. Randomized control trials have demonstrated conflicting results with regards to the benefit of laparoscopic sigmoidectomy over conservative management in resolving symptoms and improving quality of life. In the future, more data may clarify the optimal management for this group of patients. Elective surgery is not recommended for patients with minimal symptoms and no clear evidence of persisting or recurrent disease, as the risks of surgery usually outweigh the potential benefits. Patient preference is an important consideration in any decision for surgery and should be taken into account along with all of the above factors in order to reach an informed decision.
3.2 Laparoscopic Surgery
At present, data concerning laparoscopic surgery comes from non-randomized, prospective, and comparative studies. It has been shown to accelerate the return of bowel function as well as decrease the length of hospital stay. In some studies, laparoscopy has also shown to carry similar rates of complications in comparison to open resection. However, other trials have shown significant differences in the rate of incisional hernias, trocar site hernias, as well as bowel obstructions in favor of laparoscopy. Although these outcomes are of clinical importance, the differences in the rates of these complications cannot be fully evaluated in relation to the overall outcome on the general patient's health. Several studies have demonstrated that patients who undergo laparoscopic sigmoid resection have a shorter time to return to a regular diet, a decrease in ostomy formation, as well as an improvement in postoperative quality of life as compared to those who undergo open sigmoid resection. A recent Cochrane review has found that there is not enough current evidence to advocate laparoscopic resection over open resection for diverticular disease. Randomized, controlled studies with longer follow-up are needed to fully evaluate the long-term benefits of laparoscopic surgery in comparison to open surgery.
3.3 Bowel Resection
The most severe cases with life-threatening complications such as peritonitis or abscess may require emergency surgery, which carries a higher rate of complications than elective surgery. In all cases of bowel resection, patients are typically placed on a restricted diet and given a regimen of antibiotics to support the healing process. Bowel resection may also result in short-term lifestyle changes such as avoidance of heavy lifting and increased rest to prevent complications. Success rates for diverticulitis surgery, regardless of method, are estimated at roughly 85%. It is important for all patients to consult with their surgeon to determine the most appropriate procedure, given the specific nature and severity of their condition.
During a primary resection of the affected bowel, the affected portion of the colon is removed and the colon is either sewn back together or a colostomy is performed to allow the healthy portion of the colon to heal. This procedure is sometimes performed in two stages. The first stage involves a resection of the affected bowel and a temporary colostomy to allow the colon to heal. The second stage involves the closure of the colostomy. Another variation of this surgery is a resection with a colostomy, or Hartmann's procedure. This procedure involves removing the affected portion of the colon and sealing it off from the rectum with the upper portion of the colon, which is then attached to the colon wall. This creates a temporary colostomy, and the seal between the two colonic sections may be later reversed in a subsequent surgery. Although these procedures are the most invasive, they also carry the highest success rates, even for complicated cases. Success rates typically range from 90-100%, but the decision to perform these procedures on younger patients may be impacted by concerns over the risk of postoperative complications and the effect of a colostomy on quality of life.
4. Lifestyle Modifications
High fiber diet has been shown to decrease the incidence of diverticulosis and the likelihood of complications from diverticulosis. In a study of American men, those who consumed at least 7 g of fiber per 1000 calories per day had a 45% lower risk of getting diverticulosis compared with their counterparts who consumed low levels of fiber. The men who had diverticulosis and consumed a low-fiber diet were more likely to develop symptomatic diverticulosis compared to those who consumed more fiber. In particular, a diet high in cereal fiber found to be protective against the development of diverticulosis. Population with diverticulosis, previous recommendations focused on avoidance of nuts and seeds in hopes of preventing diverticulitis. Data suggest that nut and popcorn consumption does not increase the risk of diverticulitis and is associated with a lower risk of diverticulosis. Therefore, advice to avoid nuts and seeds in people with diverticulosis was not proven and likely resulted from a failure to distinguish between diverticulosis and symptomatic diverticulosis. The American Gastroenterological Association recommends that patients with established diverticulosis consume a high-fiber diet. High-fiber diet is more likely beneficial for the treatment of diverticulosis than prevention of symptoms since symptoms are more likely related to irritable bowel syndrome. In a study of postmenopausal women, those with a high dietary fiber intake were less likely to develop new onset, persistent, or recurring symptoms of severe constipation compared to women with low fiber intake, although the source of fiber making the difference is unclear.
Dietary fiber is the part of plants that is not digested in the human stomach. It is found primarily in fruits, vegetables, whole grains, and legumes. Fiber adds bulk to the diet and is fermented by bacteria in the colon. It is recommended that patients with diverticulosis eat a high-fiber diet to help prevent symptoms associated with diverticulosis, although the benefit of a high-fiber diet for the treatment of diverticulosis is not proven.
High-fiber Diet
4.1 High-Fiber Diet
Unfortunately, simple sugars can speed the progression of infection in the colon and lead to inflammation. It is thought that by introducing a regular high-fiber diet, the possibility of infection may be decreased by shortening the time that stool remains in the colon. It will still be necessary to avoid popcorn and certain nuts that might obstruct the opening of the diverticula. A low residue or clear liquid diet is often prescribed in the increase and acute phase of diverticulitis. But once the infection has cleared, the doctor may recommend a gradual increase in fiber intake in order to prevent future episodes. Normally it takes about 6-8 years to reach the full benefit and prevent recurrence of diverticulitis. A high-fiber diet is not proven to eliminate diverticula, but there is evidence that it can prevent the disease.
A high-fiber diet has been linked with a reduced incidence of diverticulitis. Increased dietary fiber promotes the formation of bulky, soft stool, and many experts believe that this may help to prevent the development of diverticula. Diverticula form when weak spots in the colon give way under pressure. The colon's muscle layers thicken as we age, and this may narrow the pockets, leading to infection or inflammation. People who suffer from diverticulosis have learned that once the condition develops, they should frequently switch to a clear liquid diet in order to help calm an episode of diverticulitis. While it is natural to avoid foods that might "plug you up," such as bananas, rice, or toast, the rest of the clear liquid diet is mostly made up of simple sugars and at the same time provides little nourishment.
4.2 Regular Exercise
Despite these assumed benefits, significant evidence exists that shows a potential increase in risk of diverticular disease associated with heavy, vigorous exercise. Runner's and athlete's studies have shown that athleticism is associated with an increased prevalence of diverticulosis. An American study found that men engaging in high physical activity are more likely to develop diverticulitis. It is suggested that the increase in abdominal pressure that occurs in heavy lifting or high force sports may be the cause of this increased risk. With the patient in mind it is best to avoid this type of exercise. Unfortunately there is no specific research into the type, duration or intensity of exercise to provide evidence based guidance for patients. Given the potential risks, the best advice is for patients to stick with low to moderate intensity exercise.
Regular exercise is beneficial in preventing and managing a variety of different health-related conditions. The benefits of regular exercise in those with diverticulosis have not yet been proven, but exercises are of some benefit to sufferers with diverticulitis. Anecdotal evidence exists that suggests exercise and general physical activity can alleviate symptoms and prevent recurrence. This is supported by a US study which found that men who are more physically active have a lower admission rate for diverticulitis. Regular exercise is also known to alleviate or prevent concomitant conditions, such as IBS and obesity. Finally, exercise is associated with a reduced need for surgery in diverticular disease.
4.3 Stress Management
Stress management can take many forms and may vary from patient to patient. Behavioral-cognitive techniques have been shown to be effective in reducing IBS symptoms and may be the same for diverticulitis. Techniques such as relaxation training, hypnosis, and cognitive-behavioral and educational interventions have all been successful in reducing stress levels in other conditions. These approaches are better learned with the help of a therapist, and most have been shown to have lasting effects that benefit patients.
The relationship between stress and diverticulitis is not yet fully understood, but it is known that stress can exacerbate the condition. This increased severity is likely due to the involvement of the immune system in the disease. Stress can weaken the immune system, which can lead to infection of the diverticula and subsequent inflammation. Elevation of stress can also cause increased pain and discomfort of diverticulitis. Therefore, it is important for patients to manage their stress in order to limit the exacerbation of this disease.