Consultation for Diverticulitis This is part of a series of consultations with surgery specialists at the University of California, San Diego. In this hypothetical conversation between patient and doctor, we present an example case that is a composite of the most common signs and symptoms we see in patients who have this problem, along with the standard exams and treatments we recommend in a typical case. Whether or how a person is affected by a particular disease or problem can depend on the person’s age, gender, or race. In each consultation we present on the UCSD web site, we will indicate whether gender, age, or race makes a difference. The following consultation about diverticulitis applies to adult women and men. In our example, the patient is an adult man. This consultation is presented for purposes of general information. If you think you may have this problem, please see your doctor to discuss your individual case and the exams and treatments that are best for you.

Introduction

The colon ( large intestine) can develop small pouches that bulge out through weak spots in the intestinal wall. These pouches are called diverticula (see illustration below). Diverticula usually do not cause problems, but they can become inflamed or infected. The result is diverticulitis, a condition that requires treatment. Mild cases can be treated with rest, dietary changes, and antibiotics. Some cases require surgery.

Diverticulitis usually affects men or women over the age of 50, although it can occur in younger people. When diverticulitis is chronic, it can lead to other problems, such as a fistula, which is an abnormal connection between the diverticular pouch and the skin or between the pouch and another organ. In some cases, the infected pouch may perforate and cause an abscess. An abscess is a larger and more severe infection that often requires surgery.

Consultation

Doctor: Hello, I’m Dr. Ramamoorthy. How are you?

Patient: I’m fine.

Doctor: What brings you to see me today?

Patient: I’m having problems with my colon and my urinary tract. My primary care physician referred me to you because he has done some tests and he thinks I may have diverticulitis, but I don’t understand what that means.

Doctor: All right. I’d like to start by asking you some questions, and then we’ll review your test results and talk about what’s going on. What sort of symptoms are you having?

Patient: I’ve had several urinary tract infections lately. And I have pain in my abdomen, sometimes really severe pain.

Doctor: How long has this been going on?

Patient: A couple of months.

Doctor: Where in your abdomen do you feel the pain, and could you describe it for me?

Patient: It’s like a crampy pain on the left side, sort of lower down over like where my belt is.

Doctor: And when do you have the pain? Is it all the time?

Patient: The pains tend to be worse when I eat, but I can have them all the time. They’re really getting unpleasant.

Doctor: Have you had to go to the emergency room or to the hospital because of the pain?

Patient: Yes. I’ve been to the Emergency Room twice because the pain was so severe that I couldn’t take it anymore. I was worried that I had appendicitis or something.

Doctor: And I see from your records that you’ve had a CT scan of your abdomen.

Patient: Yes. My primary care doctor ordered it, when the results came back he told me he thought it was diverticulitis. I don’t know what diverticulitis is because he never explained it to me.

Doctor: Diverticulitis is an infectious process that predominantly occurs on the left side of the colon. Most often, it happens in people over the age of 50, but we have seen it in patients who are younger than 50.

Patient: What causes it?

Doctor: As you may know, it is not unusual for small pouches or sacs to develop on the outside of your colon, which is your large intestine. This often happens as we get older, and it may not cause any problems at all. However, digested food can become trapped in these pouches, and then they tend to get infected. We call the pouches “diverticula,” and the infection is known as diverticulitis.

Patient: Is it serious?

Doctor: It can be. In some people, diverticulitis can cause a localized infection called an abscess. An abscess can make someone very ill and bring them to the emergency room with severe pain and fevers and chills. Sometimes one of the sacs can perforate, meaning that it develops a hole, and this can allow the infection to spread throughout your body.

Patient: Why does it perforate? Is it because that sac is weaker than the colon?

Doctor: Yes, the wall of the sac is thinner than the wall of the colon, and the sac is under some pressure as well.

Patient: Then, what you are explaining is I get this out-pouching and it gets food or something trapped in it… digested food, I guess. And then that breaks through the wall.

Doctor: Right. Because the wall is not very strong, and then it causes infection, sometimes localized like I said in the form of an abscess. Sometimes there can be a very massive infection where the entire abdomen has become infected, and in that case it would be necessary to do an emergency operation. Another problem that can occur is a fistula, which is an abnormal connection to a nearby organ such as the bladder.

Patient: Do you think that one of these sacs is somehow connected to my bladder, and that’s why I’m getting urinary tract infections?

Doctor: Yes. First of all, your symptoms do suggest that this is happening, because you have left lower quadrant pain and you have had multiple recurrent urinary tract infections. In addition, your CT scan shows a fistula, a connection between your colon and bladder. This is very common in men and women with diverticular disease. We call it complicated diverticulitis.

Patient: Why do you call it “complicated”?

Doctor: Because you have a fistula that has developed as a result of the infection.

Patient: So, what do we do now, Doc? Will I have to have surgery?

Doctor: If you do have diverticulitis with a fistula, then we would do a surgery, and I’ll talk more about than in a moment. Our first step is to be one hundred percent certain that diverticulitis is our diagnosis. To do that, we usually like to begin by treating you with antibiotics to make sure that we have gotten rid of most of the infection. That doesn’t eliminate the fistula that may have already formed, or the chronic inflamed state of the colon, but it calms the infection down so that we can perform a colonoscopy. It is very important to do a colonoscopy to be sure that this is diverticular disease and not another problem such as a cancer.

Patient: I’ve already been on antibiotics more than once. I’m on antibiotics now.

Doctor: Excellent, then we know that your diverticular disease has begun to calm down. Are you having any more left lower quadrant pain currently?

Patient: No, but when I finish the antibiotics, then it always comes back.

Doctor: Right. So we’ll keep you on antibiotics. We usually like to wait about four weeks from your last episode of left lower quadrant pain before we do a colonoscopy.

Patient: Four weeks on antibiotics?

Doctor: Correct.

Patient: I’ve never been on antibiotics that long.

Doctor: You are currently and chronically infected, and the only way to keep you from getting continually infected from your fistula and your diverticular disease prior to operation is to keep you on antibiotics so that we can perform your colonoscopy safely.

Patient: I thought antibiotics were bad for you. Is it safe to go on them for four weeks?

Doctor: Normally we don’t like to keep patients on antibiotics that long, but in your situation we believe the benefits outweigh the risks.

Patient: So after four weeks of antibiotics and when I’m feeling OK…

Doctor: We’ll perform a colonoscopy.

Patient: I have never had a colonoscopy. What is it, exactly?

Doctor: When we do a colonoscopy, we place a scope into your anus and through the rest of your colon to take a look on the inside of the colon. By doing that, we will be able to confirm that our diagnosis of diverticulitis is correct, and that there is not another kind of problem going on.

Patient: When you do have the correct diagnosis, what do you do then?

Doctor: Once we get the colonoscopy and we’ve done a thorough medical evaluation, we would plan to do an operation called a laparoscopic sigmoid resection surgery.

Patient: What is that?

Doctor: It’s an operation to remove the infected part of your colon and to close the hole in your bladder. It’s referred to as a “sigmoid resection” because diverticular disease usually develops in the sigmoid colon, which is in the left lowerside, where you are feeling the pain.

Patient: Is that the only way to treat this problem?

Doctor: Yes. You have complicated diverticulitis, which means that you’ve developed complications. The only way to treat complicated diverticulitis is to remove that portion of the colon.

Patient: You’re going to cut out a piece of my colon? How much of the colon?

Doctor: It will be a small portion of the colon, and we will determine that after we do the colonoscopy when we know exactly where the infection is.

Patient: Does this mean you’re going to make one of those holes in my stomach where everything comes out into a bag?

Doctor: No. What you’re describing is a colostomy. We often perform colostomies for patients who come in on an emergency basis because they have had a massive perforation or a massive infection from the diverticular disease. In your case, you came early and we can treat this on an elective basis, and the likelihood of you having to have a colostomy will be very, very low.

Patient: And you also operate on my bladder?

Doctor: Often we’ll close the hole in the bladder. Sometimes it’s so small that we don’t close it. In that case we keep a catheter in your bladder for about two weeks after surgery to allow that hole to close up on its own.

Patient: Do I have to go to the hospital for this?

Doctor: Yes. You’ll be in the hospital the day of surgery and about a week after surgery recovering from your operation.

Patient: How long before I can get back to my normal activities?

Doctor: After a week in the hospital, your recovery is about two weeks at home. We put you on a low-residue diet, which is low fiber, to begin with. Once you start having regular bowel movements again and are almost back at your baseline, we’ll start you on a high-fiber diet. Then you should remain on the high-fiber diet for the rest of your life so that you can avoid constipation.

Patient: What are the risks of the surgery?

The biggest surgical risk is infection, which can happen inside the abdomen or inside the wound. An infection inside the abdomen, which is an abscess, would be treated by IV antibiotics. Sometimes it requires drainage by the radiologist. A more significant infection can occur if the two ends of the bowel don’t heal together properly and the contents of the bowel are allowed to “leak” out into the abdominal cavity, which can make a patient very sick. Small leaks are treated by IV antibiotics, sometimes by drainage. Larger leaks may require a trip back to the operating room. The incidence of leak is less than 5% for all bowel surgery. The rates go up for patients who are significantly immunocompromised or those who are on steroids.

More superficial infections can involve just the wound itself, where the wound may get red or even contain a little bit of purulent material. These are treated by antibiotics and by opening the skin to let the infection out. That can prolong someone’s hospitalization by a few days, but generally does not deter from someone’s overall health and well-being. Wound infections happen anywhere from 15 to 30% of cases, mainly related to the fact that we are operating on the bowel, which is not a very clean organ to begin with.

Patient: I knew someone who had colon surgery and then later they had a small bowel obstruction. Can that happen with this surgery?

Doctor: Small bowel obstructions occur in 20% of patients who have any kind of abdominal surgery, whether it’s an appendectomy, a C-section, or a colon resection. Small bowel obstructions are due to scar tissue that develops after the abdomen has been operated on. In most patients, it does not require anything more than hospitalization and bowel rest. In a small percentage of patients, it may require an additional operation.

Patient: Will I have to have a blood transfusion during surgery?

Doctor: There’s always risk of bleeding, but a blood transfusion usually is not necessary for this type of operation.

Patient: Are there any other risks?

Doctor: The other risk is to an important structure called the ureter, which is located close to the sigmoid and left colon. We take precautions to minimize the risk of injuring the ureter during the operation,. Injury to the ureter is a rare complication.

Patient: Anything else?

Doctor: There are anesthesia risks with any surgery The anesthesiologist we will go over those in more detail when we do your preoperative evaluation.

Patient: Since I’m a traveling salesman and live pretty much off commission, when will I be able to get back to work?

Doctor: If we perform your surgery laparoscopically, it will be around two weeks before you are ready to go back to work. If we do the surgery using a standard open procedure, healing takes about four weeks before people feel well enough to put in a full day of work.

Patient: Is it important for me to have this operation soon?

Doctor: Absolutely. With complicated diverticulitis, the longer you wait, the higher the risk of developing the severe perforation that I spoke about earlier.

Patient: I’ve been asking so many questions, but I really appreciate your taking the time. I’d like to get started making arrangements for the surgery.

Doctor: I will have my assistant call you to make the arrangements. Thank you for coming in to see me today.