Dr. Maher Abbas is an American Board Certified Colon and Rectal Surgeon who performs the latest and most advanced procedures to treat conditions affecting the small intestine, colon, rectum, and anus. He is a leader in minimally invasive and endoscopic surgery. With over 14,000 operations and procedures experience, he provides state of the art treatment to his patients.
What is diverticulosis and diverticulitis?
Diverticulosis is a condition that affects the digestive system, most commonly the left side of the colon. The right colon can be affected, especially in Asian people. Diverticula are small, bulging pouches that protrude through the lining of the intestine. Diverticulosis is very common, especially after age 40. Diverticulosis seldom causes any symptoms. However sometimes one or more diverticula can become inflamed and infected, a condition called diverticulitis. Factors that increase the risk of diverticulitis include aging, a sedentary lifestyle, obesity, and a diet low in fiber and high in fats. In addition, some medications have been associated with diverticulitis including medications that suppress the immune system such as steroids, constipating medications such as opioid pain killers, or nonsteroidal anti-inflammatory medications such as naproxen and ibuprofen.
What are the symptoms of diverticulitis?
The majority of patients with diverticulosis have no symptoms. When the pockets get inflamed, the patient develops diverticulitis. The symptoms include one or more of the following:
- Abdominal pain and cramping [typically in the left lower abdomen but it can present on the right side, middle of the abdomen, or throughout]
- Constipation or diarrhea
- Nausea and/or vomiting
Patients with complicated diverticulitis from perforation (a hole in the bowel) can present with diffuse abdominal pain that is worse with coughing or movement. An abscess (a collection of infected pus) can occur inside the abdomen or pelvis. Long-term complications of untreated diverticulitis include narrowing of the colon (stricture) or fistula (abnormal communication) to the bladder or vagina, especially in women who had previous removal of the uterus. Symptoms of bladder fistula from the colon are air or stool in the urine (cloudy urine) and/or recurrent bladder infection. It can happen in both men and women. In women with vaginal fistula, the symptoms are usually passage of air, pus, or stool into the vagina with recurrent urine infection or yeast vaginal infections.
Patients with diverticulosis can develop heavy rectal bleeding but without symptoms of diverticulitis. It typically occurs in older patients.
How is diverticulitis diagnosed?
It is important to properly diagnose diverticulitis during an active attack. Lower abdominal pain can be caused by a variety of conditions and it is important to undergo diagnostic testing in order to establish whether a patient has diverticulitis or not. The following are the most commonly ordered tests:
Blood tests: CBC (complete blood count), CRP (C reactive protein) to assess degree of inflammation, kidney function test, urine analysis and culture if needed
Imaging studies: computed tomography scan (CT) remains the best way to establish the diagnosis of diverticulitis. Barium or gastrografin enema is another study that can be done to check for diverticulosis when the patient is recovered and has no symptoms of active inflammation [Figure 1]
Figure 1 – Diverticulosis of the left colon seen during barium enema X-Ray (Numerous small pockets on the right side of the picture)
Procedures: Colonoscopy is a procedure that allows Dr. Maher Abbas to look inside the colon to assess the degree of diverticulosis [Figure 2]. However, a period of 4 to 6 weeks of recovery after an attack of diverticulitis [Figure 3] is recommended before performing a colonoscopy. The purpose of the procedure is to check the extent of diverticulosis and to exclude other conditions such as colitis, colorectal polyps or cancer
Figure 2 – Diverticulosis seen during colonoscopy (Pockets without inflammation)
Figure 3 – Diverticulitis seen during colonoscopy in a patient with persistent pain (Red and inflamed pockets)
Stool tests: for patients with diarrhea, calprotectin level (to assess for degree of inflammation in the intestine), clostridium difficile bacteria toxin, FOBT (fecal occult blood test), and/or stool studies for ova and parasites is recommended.
How to prevent diverticulitis?
Eating a high fiber balanced diet that is low in fat can be beneficial in minimizing the risk of developing diverticulitis. Physical activity with regular exercising, avoiding constipation and drinking a minimum of 8 glasses of water a day is helpful for overall health and can help prevent acute diverticulitis.
How is diverticulitis treated?
The majority of patients with acute diverticulitis can be treated successfully with medications on outpatient basis at home. Patients with nausea and vomiting, high fever, or severe abdominal pain require hospitalization. About 80% of patients hospitalized with acute diverticulitis are treated medically without the need for surgery. Medical treatment includes:
Antibiotics: most patients receive 1 or more antibiotics to treat the infection. Mild cases of diverticulitis maybe treated without antibiotics
Pain relievers: patient with mild to moderate pain can be treated with acetaminophen (paracetamol). Hospitalized patients with severe pain may require opioids medications such as morphine and antispasmodics if experiencing severe spasm
Modified diet: A liquid diet that is low in fiber content is advised for several days to allow the bowel to heal. Patients with severe symptoms can benefit from bowel rest and intravenous hydration and nutrition.
While the majority of patients with acute diverticulitis are treated medically, some patients will require a surgical procedure. An operation is advisable for the following situations:
- Abscess inside the abdomen or pelvis that cannot be drained or suctioned with a tube by a radiologist
- Perforation with peritonitis (diffuse abdominal pain due to pus or feces spillage inside the abdomen, high fever, and distention)
- Persistent or worsening symptoms that do not respond to intravenous antibiotics
- Fistula to the bladder or vagina
- Multiple episodes of diverticulitis (typically three or more)
- Narrowing of the colon (stricture) causing obstruction
- Suspicion for a mass or cancer in cases with incomplete colonoscopy
- Weakened immune system such as in patients with immunodeficiency, transplant, or those receiving immunosuppression for medical conditions.
Surgery for diverticulitis entails removing the portion of the colon that is inflamed. Depending on the patient presentation and status, the bowel can be reattached or in some cases there is a need for a stoma (an opening in the bowel that is attached to the abdominal wall) to allow waste to collect in a bag [see Colostomy and Ileostomy]. A stoma can be needed in the emergency setting or for very difficult cases with extensive inflammation. At a later stage, a consideration is made to close the stoma.
The quality of the surgery, the judgment and expertise of the surgeon can make a huge difference for the patient. Colorectal surgery is the surgical specialty that has extensive expertise with diverticulitis. While there are various techniques, Laparoscopic Camera Surgery (keyhole surgery) is the preferred method of Dr. Maher Abbas when it comes to treating patients with diverticulitis. Laparoscopic camera surgery is associated with less pain, faster recovery, and fewer short and long-term complications compared to other techniques. But laparoscopic camera surgery requires a lot of advanced skills and experience in order to achieve optimal outcome. Dr. Maher Abbas is an expert in minimally invasive techniques including laparoscopic camera surgery and endoscopic surgery. In addition, he prefers to avoid a stoma in the majority of patients.
If you would like to schedule a consultation with Dr. Maher Abbas, click here. If you have previously undergone any testing, kindly bring all outside reports and imaging studies for Dr. Maher Abbas to review the day of your consultation.