Author: James Kurtz, D.O., FACOS, FACS, advanced GI surgeon, Providence Surgery Clinic – East
Diverticulosis is one of the most common gastrointestinal disorders in the United States, affecting about 60% of the population by age 60. Diverticular disease is a broad term encompassing all the potential complications that can arise from diverticulosis. Diverticular bleeding and diverticulitis are the two most common manifestations of diverticular disease.
Diverticular bleeding largely is treated conservatively, using endoscopy, intravascular procedures or very rarely surgery. In contrast to diverticulitis, diverticular bleeding has been declining in recent decades.
Incidences of diverticulitis
Recent studies show that only about 5% of individuals with diverticulosis will develop diverticulitis during their lifetime. However, this still accounts for more than 2.7 million outpatient visits and 200,000 inpatient admissions, at a cost of more than $2 billion annually in the U.S. The incidence of diverticulitis has increased over time and with patient age. The greatest relative increase, however, has developed in younger populations, with a 132% increase from 1980 through 2007 in the age range of 40-49 years old.
Diverticulitis is believed to arise from a combination of genetic, lifestyle and environmental risk factors that include a Western diet low in fiber. Although the true pathophysiology of diverticulitis isn’t fully understood, more recent research has highlighted chronic inflammation and alterations in the gut microbiome as key components as well. This all suggests that diverticulitis is an inflammatory condition that can result in micro-perforation and is not a result of micro-perforation itself. Nuts and seeds do not appear to increase the risk of diverticulitis and have even been shown to decrease the incidence in as least one prospective cohort study.
Uncomplicated vs. complicated diverticulitis
Treatment of diverticulitis varies based on the severity of disease and presence of complications. It’s useful to consider diverticulitis within two broad categories: uncomplicated or complicated.
Uncomplicated diverticulitis
Patients with uncomplicated diverticulitis traditionally have been treated with antibiotics alone. Recent studies have called this practice into question, noting that antibiotics may not hasten recovery or improve outcomes in low-risk patients. The latest American Society of Colon and Surgeons (ASCRS) clinical practice guidelines advocate for antibiotics in higher-risk patients with significant comorbidities, signs of systemic infection or immunosuppression.
Uncomplicated diverticulitis should not require any more treatment than antibiotics at the discretion of the treating physician. However, for patients with persistent symptoms that affect their quality of life, surgery can be considered on a selective basis.
Complicated diverticulitis
About 12% of all patients with diverticulitis will develop a complication. This includes abscess, perforation, obstruction or fistula. As our CT scan images become more detailed, it’s important to point out that a para-colonic phlegmon or small amounts of extra-luminal gas should not dictate a specific therapy. Once a patient has recovered from an acute complicated diverticulitis, most guidelines recommend that they undergo colonoscopy in six to eight weeks if they have not had one recently. The true incidence of malignancy in complicated diverticulitis is unknown but has been reported as anywhere from 1.3% to 11%.
Abscess is the most common complication accounting for roughly 70% of complicated cases. Antibiotic treatment alone often is successful for abscess <3 cm in size. The addition of percutaneous drainage in abscess >3 cm leads to successful treatment in about 80% of cases. Success is defined as no emergent surgery required, no worsening sepsis and no recurrence of abscess within 20 days.
For patients with persistent quality-of-life symptoms, they may be candidates for surgery. It’s important to note that when a patient has free air, a significant amount of free fluid or generalized peritonitis, they often require emergency surgery. Depending on the stability of the patient, surgery may be performed with a minimally invasive or an open approach.
Fistula is another complication associated with diverticulitis. This abnormal connection from the colon most often is to the bladder or vagina but also can occur to the small bowel or cecum. While it is possible to see a fistula on imaging studies, colonoscopy or cystoscopy, it is more common that these studies are inconclusive. Therefore, if a complicated diverticulitis patient experiences pneumaturia, fecaluria or stool from vagina, then most surgeons assume a fistula is present. Antibiotics may be necessary for these patients until the time of surgery. It is unlikely that a fistula will heal without surgery, and these patients should be referred to a surgeon skilled in colon resection.
Obstruction or stricture also can occur and is best treated with surgery. If the patient experiences obstipation or complete obstruction, this surgical plan should be expedited.
Enhanced recovery after surgery
In my fellowship I was trained in an excellent ERAS (enhanced recovery after surgery) protocol and gained a significant amount of experience with robotic colorectal procedures. I was able to transfer these outcomes to my practice in Pennsylvania for the last few years and now am pleased to bring them here to Providence Portland Medical Center.
About 50% of my patients discharge home on post-operative day #1, and the rest go home on postoperative day #2. Patients are allowed to eat a low-fiber diet immediately after surgery, and their catheter is removed in recovery prior to returning to their room. All patients are required to ambulate, void, have bowel function and have their pain controlled prior to discharge. Our goal is to perform even urgent or emergent diverticulitis cases with similar minimally invasive techniques.
References
Article references are available upon request.
Source for images: Strate LL, Morris AM. Epidemiology, Pathophysiology and Treatment of Diverticulitis. Gastroenterology. 2019 April; 156(5): 1282-1289.el. Doi: 10.1053/j.gastro.2018.12.033
About Dr. Kurtz
Dr. Kurtz completed medical school in Denver, Colorado, and general surgery training in Columbus, Ohio. He then received additional training in an advanced GI fellowship at Methodist Richardson Medical Center in Texas. The fellowship training consisted of an extensive operative experience in foregut (including esophagectomies), hepatopancreaticobiliary, bariatric revisional surgery, and colorectal, with a strong emphasis on minimally invasive techniques, including robotics and laparoscopy.
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Providence Surgery Clinic - East
5050 NE Hoyt St., Suite 610
Portland, OR 97213
503-467-4761
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