No longer a condition affecting mostly older people in Western countries, diverticulitis now can develop in people of all ages—even people in their late 20s and early 30s. Recent studies are helping practitioners gain a better understanding of the causes of diverticulitis and re-evaluate effective treatment.
Bottom Line Personal interviewed V. Liana Tsikitis, MD, MBA, MCR, a gastrointestinal surgeon and author of a new study on diverticulitis. We wanted to know what diverticulitis is…and how you can avoid it.
What it is: Over time, little pouches called diverticula develop along the lining of the intestines, a condition called diverticulosis. They develop most often in the sigmoid colon of the large intestine but can appear anywhere along the small or large intestine. Why they occur isn’t fully understood, but we do know there’s no way apart from surgery to get rid of them once they occur. By some estimates, more than half of American adults over age 60 have these pouches, and many don’t even know they have them. In fact, you might find out about them only from a colonoscopy report.
For some people who have diverticulosis, one or more of the pouches can become inflamed. When that happens, the condition changes from diverticulosis to diverticulitis (the ending “itis” means inflammation).
Diverticulitis typically is diagnosed as either uncomplicated or complicated based on the results of an imaging study such as a CT scan. Though still painful, diverticulitis is considered uncomplicated when it is limited to inflammation of pouches. Symptoms, including discomfort or mild pain in one localized spot, tend to go away after a few days but flare-ups are likely to recur.
Diverticulitis becomes complicated once it progresses beyond just inflammation. Complications include developing a fistula, or abnormal connection between parts of the colon or the colon and another organ…a perforation, or tear, in the colon…an abscess, or infection, within a pouch…or a stricture, a narrowing of the colon.
What causes it: It is hard to predict who will get diverticulitis and how serious it will be. That’s because everyone follows their own diet and lifestyle and has their own genetic makeup. In fact, one of the newest areas of research surrounding diverticulitis involves DNA—specific genes that you inherit from your parents may predispose you to the condition. A family history of diverticulitis usually is one of the predisposing factors to developing the condition in adulthood.
Think of your genes as your baseline, and then consider the environmental factors that can ramp up your risk—what you eat and other lifestyle factors—and how all these factors affect your gut microbiome. Not getting enough fiber and being constipated frequently (and straining to push out stool) may play a role. Smoking has been implicated, too—it destroys collagen (part of the makeup of the intestinal lining) and can lead to weakness along that wall, leaving it vulnerable to the formation of pouches.
While diverticulitis is more likely in people who don’t eat a healthy diet, don’t have good colonic health and don’t exercise, it can affect people who exercise, get enough fiber and are at a normal weight. As we’ve moved further away from our ancestors’ active hunter-gatherer lifestyle and become couch potatoes, we’ve seen more cases of diverticulitis.
What to watch out for: The first sign often is discomfort or mild pain in one spot deep in the abdomen on the left side. Early on, you might notice it when you sit down or get up. Within a day or even a few hours, the pain can become more significant, to the point where you’re doubled over and feel nauseated. You also may notice changes when you have a bowel movement—the stool may become narrower, and you may have constipation or diarrhea. Inflammation and infection, as in the case of an abscess, often will cause flulike symptoms—fever, chills and a general malaise.
How it is treated: Treatment will be tailored to your specific diagnosis. Some people with uncomplicated diverticulitis who have intermittent flares can be treated at home under a doctor’s supervision. You likely will have to rest for two or three days and follow a clear-liquid diet to give your bowel a break from foods that require a lot of digestion, such as those with high fiber content. Standard protocol also has been to take a course of antibiotics, but some medical societies in the US and Europe have started to change their position about it. Most important: Get checked by your doctor, and have a discussion about the best course of treatment for you.
People with complicated diverticulitis and severe pain are likely to head to the ER or be admitted to the hospital. Those with very serious complications, such as when a section of colon is perforated or so diseased that it can’t recover, often need a colon resection to remove the affected part. This also may stop future attacks.
Sometimes, surgery is needed immediately…other times, it might be scheduled after the attack has subsided, when you’re in better shape to undergo the operation. In the operating room, the surgeon will determine whether the two healthy ends of the colon can be reattached…or you need a colostomy, in which the remaining colon is attached to the abdominal wall and an opening is created through which stool passes into a colostomy bag. For many patients, the colostomy is only temporary, but if you’re not strong enough to go through another procedure, a permanent colostomy might be the safer route.
There are no guaranteed ways to prevent diverticulitis, but there are steps to lower risk or prevent another attack…
Eat more fiber. Research, including the well-known Nurses’ Health Study, has found that people with higher intakes of dietary fiber have a lower incidence of diverticulitis. You can increase fiber intake with supplements. Talk with your doctor about your options. There’s also evidence that whole fruits, notably kiwis, apples, pears and prunes, cruciferous veggies, nuts and fiber-rich cereals are particularly helpful.
While the universal goal is 30 grams of fiber a day, even people making a concerted effort typically get only about half that. Many people supplement with an over-the-counter fiber product, such as Citrucel, Metamucil or Benefiber, which also helps you avoid constipation. If that’s not enough to prevent straining on the toilet, talk to your doctor about a safe stool softener.
Follow an overall healthy diet focused not only on fruits, vegetables and whole grains, but also on legumes, poultry and fish, rather than the typical Western diet of processed, refined foods.
Avoid NSAIDs. There appears to be a link between taking nonsteroidal anti-inflammatory drugs and developing diverticulitis, so watch your dosages.
Consider taking probiotics. Probiotics, which support a healthy gut microbiome and help prevent certain gastrointestinal diseases, could improve symptoms and prevent recurring attacks, but the verdict is still out.
Important: If you have a family history of diverticulitis but haven’t had any signs of it, talk to your doctor about your risks and steps you can take.
