Understanding Diverticulosis and Diverticulitis

Any time I talk to patients about diverticular disease I make sure to clarify some terms.

Diverticulosis is a common and benign condition that tends to affect people over age 60. Diverticuli are small sacs or hernias in the colon wall which may become more common as we age. Millions of patients have diverticulosis and it is often discovered incidentally through a colonoscopy without presenting any problematic symptoms

Diverticulitis, on the other hand, is pathologic and involves inflammation, infection and often perforation of one of these sacs. While diverticulosis has no symptoms, diverticulitis typically involves pain in the abdomen, often the left lower area, and fever. It most commonly involves the left lower part of the colon.

Diverticulitis can occur in varied severity. Simple diverticulitis is treated with oral antibiotics at home. Patients make a full recovery with no residual symptoms. Many of these patients never have another issue. However, some patients go on to develop recurrent diverticulitis and can have multiple attacks over years. They typically present in the same way each time, as this is not a progressive disease. With recurrent episodes over time, patients develop scar tissue which can cause symptoms. When surgery is discussed, it is individualized and based on the patient’s overall picture.

Another variation is complicated diverticulitis, which often includes problems like abscess or fistula (connection to a local organ). These patients generally require surgery once the diverticulitis has been treated as they are at a high risk for recurrence or ongoing infection. The most extreme is a patient who presents with an actual rupture of the colon. This is a surgical emergency and can be life threatening. These patients need an urgent operation that generally requires a colostomy (stoma or bag). Most often patients who present with perforation do so on their first episode of diverticulitis.

Diverticulitis is treated with antibiotics and most patients completely recover. Every patient with a first episode of diverticulitis should have a colonoscopy 6-8 weeks after treatment to evaluate the colon, and rule out other reasons for the symptoms, including cancer. Diverticulitis was historically thought to be related to diet and inadequate fiber, but this has not been shown to be the case.

Presently we don’t know exactly what causes diverticulitis. There is some thought that genetics, diet, environment and bacteria may all play a role in the development of diverticulitis, recurrence and its complications. Classically, patients were told not to eat nuts, popcorn and seeds, but studies have looked at this specific issue and found that a strict diet does not affect whether patients have recurrence and no diet limitations are required. There is no clear way to prevent recurrence.

There is also no straightforward surgery protocol for patients with diverticulitis. It is a personalized discussion based on the patient, and his or her history and imaging. If a patient does require surgery, ideally we want to wait 6 weeks after an infection to allow the inflammation to subside. This both decreases the risks of surgery and the possibility of stoma. This also increases the likelihood that surgery can be done in a minimally invasive way (robotic or laparoscopic).

Diverticulitis is not as simple and straightforward as we previously thought and we are seeing an increase in the incidence, unrelated to diet. There are often not clear answers to treatment or prevention but evaluation by a colorectal surgeon is important in treating potential infection and can be helpful in assessing the risks of this disease, treatment and surgery options.

Call 703-280-2841 for more information or to schedule a consult.
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Katherine Khalifeh, MD, FACS, FASCRS
Dr. Khalifeh is a Johns Hopkins trained, board certified Colon and Rectal Surgeon, with specialized training in the treatment of disorders of the colon, rectum and anus, including cancer, inflammatory bowel disease, fecal incontinence, hemorrhoids, pilonidal disease and pelvic floor disorders. Born and raised in Minnesota, she earned her BS from Boston College and her MD from Johns Hopkins University. She remained at Johns Hopkins for her general surgery training and completed her Fellowship in Colon and Rectal Surgery at Washington Center Hospital in 2012. She joined Fairfax Colon and Rectal Surgery in the Fall of 2012 and became a partner in the practice in 2016. She has a unique perspective on patient care and treatment, having first been a critical care nurse for 10 years, before taking on the challenge of graduating from one of the most demanding surgical training programs in the nation. She also comes from a family of physicians, and follows in the foot-steps of both her father and grandfather pursuing a career in surgery. Dr. Khalifeh has been published in professional journals including Current Problems In Surgery, Archives of Surgery, and Journal of Critical Care. She has presented papers at conferences including the American Society of Colon and Rectal Surgeons, the Chesapeake Colorectal Society, and the American Medical Association. She is an active member both of the American Society of Colon & Rectal Surgeons and the American College of Surgeons. Her husband Marwan is a plastic and reconstructive surgeon, and together they spend their leisure time skiing, biking and traveling with their two young daughters and dog Bisou.