Imagine having abdominal pain so severe that you’re curled up in the emergency room, screaming. Your diagnosis is diverticulitis, an inflamed or infected “pouch” in the intestinal wall. A surgeon recommends that you have an operation to remove the inflamed portion of your intestine. If you don’t, you’re warned, the diverticulitis will come back…and the next time, it might rupture, requiring emergency surgery and perhaps even a colostomy (when the colon is diverted to an opening in your abdomen and you have to collect your feces in a plastic bag). So, of course, you have the surgery, right?
Not necessarily—because the operation could be a complete waste. Doctors are now realizing that, in many cases, diverticulitis is treated too aggressively, as a large-scale new study shows.
Diverticulitis is a fairly common ailment, so if you haven’t experienced it yet, your day may come. And in recent years, hospital admissions for elective diverticulitis surgery have increased by about 25% to 30%. Here’s what you need to know to avoid unnecessary surgery…
Diverticula are small, bulging pouches that can form anywhere along the digestive tract but most commonly develop in the large intestine. About half of Americans over age 60 have these pouches, which are typically the size of a marble. Most pouches cause no problems, so people don’t even know that they have them. But if a pouch gets infected or inflamed, the likely symptoms include sudden and severe abdominal pain, fever, nausea, vomiting, constipation or diarrhea and/or rectal bleeding.
The majority of diverticulitis cases are uncomplicated, albeit painful. However, in some cases, serious complications do develop. These include a perforation (a hole in the intestinal wall)…fistula (a hole that creates a passageway between the intestine and the abdominal wall, bladder, uterus or vagina)…abscess (a collection of pus in the swollen pouch)…or obstruction (intestinal blockage). Fear of such complications—or fear of a recurrence that might lead to complications—has been a driving force behind the common practice of doing surgery even in uncomplicated diverticulitis cases.
Recently, researchers from the University of Michigan conducted a review of 80 scientific studies on diverticulitis to evaluate the effectiveness of current treatments. I called the study’s lead author, Arden Morris, MD. Here are some main factors behind her conclusion that surgery often is not warranted…
• Recurrence is not as common as was thought. Some patients are told that, once diverticulitis develops, a recurrence or multiple recurrences are practically guaranteed unless surgery is done. However, Dr. Morris cited a study of 2,366 diverticulitis patients who did not have surgery…and after nearly nine years of follow-up, only 13% had experienced a recurrence and less than 4% had more than one recurrence.
• Recurrence is not as dangerous as had been believed. Even for people who do have a recurrence or who develop chronic diverticulitis, fewer than 5% developed one of the dreaded complications. In fact, it now appears that subsequent episodes of diverticulitis typically are less severe, not worse, than initial episodes. No one knows exactly why that’s the case, but one theory is that the inflammation in the first episode triggers nearby structures to reinforce themselves and bolster the area to help guard against perforation in the event that the inflammation recurs.
• Surgery provides no guarantee against future problems. Diverticulitis surgery itself has a fairly high complication rate…and up to 25% of patients who did have the operation still experienced unresolved symptoms afterward. Also, in more than one in three cases of recurrences, the inflammation or infection developed in a different area of the intestine than the original attack—so surgery that removed the initial pouch would not have prevented the second pouch from becoming symptomatic.
• Complications are even more common in a first episode than in a recurrent episode. In one study of patients who did have complicated diverticulitis (with an abscess or perforation), nearly three-quarters had had no previous “warning” episode—contradicting the idea that the surgery prevents most complications.
None of this is to say that surgery is never appropriate for diverticulitis—because sometimes it is absolutely essential. Dr. Morris said that urgent surgery is needed if any of the following occurs…
• A patient develops sepsis, an overwhelming immune response to a bacterial infection in which chemicals released into the blood trigger widespread inflammation, leading to blood clots and leaky blood vessels.
• There is an obstruction blocking the intestine.
• An infected pouch perforates, spilling intestinal contents into the abdominal cavity.
Elective surgery should be scheduled if…
• A patient has a fistula.
• A patient has a compromised immune system (for instance, from HIV or an organ transplant), because this creates a greater infection risk overall.
When surgery is not warranted, what treatment is appropriate? It depends on the individual case, so patients need to work closely with a doctor who is knowledgeable about the latest research, Dr. Morris said. Generally, though, the options include…
• Antibiotics—maybe. In the past, patients often were kept in the hospital for several days of intravenous antibiotics. However, Dr. Morris said, recent studies have found no advantage in using intravenous rather than oral antibiotics…and even oral antibiotics don’t help much in cases of uncomplicated diverticulitis, having no effect on the rate of complications or recurrence and doing little to relieve symptoms. This means that some patients are getting antibiotics that aren’t doing them any good—and that may do harm, considering that the drugs can disrupt the normal beneficial bacteria in the gut and worsen diarrhea. Exceptions: For complicated diverticulitis, antibiotics are likely to reduce symptoms by helping limit infection and inflammation. And the drugs are absolutely warranted when a CT scan (typically done during diagnosis) shows either an abscess or a phlegmon, an area of inflammation that has not yet developed into an abscess, Dr. Morris said. An abscess also requires drainage, which can be done through a small puncture in the skin.
• Probiotics—maybe. Some experts believe that an imbalance of the normal gut bacteria contributes to chronic inflammation and diverticulitis. Dr. Morris’s review included one small study of people who were randomly assigned to take either a placebo or a supplement containing probiotics (beneficial digestive bacteria) after their diverticulitis was treated with antibiotics. There was no difference in the rate of diverticulitis recurrence between the two groups. However, those who used probiotics reported less abdominal pain and bloating.
• Anti-inflammatory medication. Diverticulitis appears to share some traits with inflammatory bowel disease (IBD), a broad term that describes several conditions characterized by chronic or recurring inflammation of the gastrointestinal tract. An anti-inflammatory drug called mesalamine (Pentasa), which is used to treat IBD, shows some promise for also reducing the underlying inflammation of the colon wall that may contribute to diverticulitis.
• Clear liquid diet at first…followed by an increase in fiber. Consuming only water, tea, broth and juice for three or four days reduces abdominal pain and gives the digestive tract a chance to recover. Generally, after several days, solid food can be gradually reintroduced. Going forward, it’s a good idea to increase your intake of fiber. Some studies show that people who eat a high-fiber diet have lower risk of ever developing diverticulitis, so even though there’s no evidence that fiber helps prevent a recurrence, it can’t hurt, Dr. Morris said. As for the old admonishment that people with a history of diverticulitis should avoid nuts, seeds and popcorn like the plague—for fear that these small, hard foods would get trapped in the pouches and trigger another flare-up—that notion has been debunked. These foods are nutritious and high in fiber, so it’s fine to go ahead and enjoy them, Dr. Morris said.
