Information in this column is provided for general educational purposes only and is not a substitute for professional medical advice, diagnosis or treatment. Consult a qualified healthcare professional regarding individual medical concerns.
The topic this month is diverticulitis. First, it helps to understand the different terms.
Diverticula, diverticulosis and diverticulitis
Diverticula are small pouches or sacs that form in weak spots in the wall of the colon, most often in the lower part of the large intestine. Diverticulosis means that these pouches are present. It becomes more common with age, and most people who have diverticulosis never develop symptoms or complications.
Diverticulitis occurs when one or more diverticula become inflamed. Infection may also be present in some cases. Fewer than 5% of people with diverticulosis develop diverticulitis. The likelihood of diverticular disease increases with age. After a first episode of diverticulitis, recurrence is possible; studies suggest roughly one in five patients will have another episode over the following years.
Symptoms
Diverticulitis most often causes abdominal pain, usually in the lower left side, and the pain may be severe. It may begin suddenly or become worse over several days. Other symptoms can include fever or chills, nausea or vomiting, constipation or diarrhea, abdominal tenderness and bloating. Blood in the stool is an alarm symptom and should be reported promptly. Diverticular bleeding can occur in people with diverticular disease, but it is not a typical symptom of uncomplicated diverticulitis.
Seek prompt medical attention for severe or worsening abdominal pain, a rigid or very tender abdomen, persistent vomiting, fever with significant pain, weakness or pallor, or rectal bleeding.
Uncomplicated and complicated diverticulitis
Most episodes are uncomplicated, meaning the inflammation remains localized and does not produce a major secondary problem. Some people have recurrent episodes or persistent symptoms after an acute attack.
Diverticulitis is considered complicated when inflammation leads to problems such as an abscess, intestinal obstruction, a fistula, perforation of the colon or peritonitis. A fistula is an abnormal passage between the colon and another organ, such as the bladder or vagina. A perforation can allow intestinal contents and bacteria to enter the abdominal cavity, causing peritonitis and potentially sepsis. Severe diverticular bleeding can also occur in people with diverticular disease and may lead to anemia or, rarely, life-threatening blood loss.
Diagnosis
Symptoms of diverticulitis can resemble those of several other conditions, so diagnosis should not be based on symptoms alone. A physician may order blood or urine tests and imaging. A CT scan of the abdomen and pelvis is commonly used to confirm diverticulitis and identify complications. Ultrasound may be used in some situations.
Colonoscopy is generally not performed during an acute attack. Depending on the severity of the episode, a patient’s history and the timing of the most recent colonoscopy, a physician may recommend one after recovery. When it is indicated, it is usually delayed for at least six to eight weeks, or until acute symptoms have completely resolved.
Medicines to use cautiously
Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin® or Advil®) and naproxen sodium (Aleve®), can increase the risk of diverticulitis or its complications. Aspirin should not be stopped when it has been prescribed for cardiovascular disease without first speaking with the prescribing clinician. For pain during diverticulitis, a healthcare professional may recommend acetaminophen rather than an NSAID.
Treatment
Treatment depends on the severity of the illness and whether complications are present. Mild, uncomplicated diverticulitis can often be treated at home. A short period of clear liquids or other easily tolerated foods may be recommended, with solid foods gradually added as symptoms improve. Pain management and adequate fluids are also important.
Antibiotics are no longer considered necessary for every otherwise healthy patient with mild, uncomplicated diverticulitis. They are used selectively and are recommended when a patient is at higher risk, is immunocompromised or frail, is clinically worsening, cannot tolerate oral intake, or has complicated disease. Hospitalization, intravenous antibiotics, drainage of an abscess or surgery may be required for severe or complicated cases.
Diet after recovery
Older advice often told people with diverticulosis or a history of diverticulitis to avoid nuts, seeds, corn, popcorn and fruits with small seeds. Current research does not support those restrictions. Unless a particular food clearly causes symptoms for an individual, these foods do not routinely need to be avoided.
After recovery from an acute episode, a high-fiber, plant-forward diet is generally encouraged. Good sources of fiber include vegetables such as broccoli, carrots, leafy greens, peas and squash; beans and lentils; whole-grain breads, cereals, brown rice and whole-wheat pasta; and fruits such as apples, pears, berries, oranges, peaches, prunes and figs. Increase fiber gradually and drink adequate fluids. If increasing fiber causes troublesome gas or bloating, discuss the amount and timing with your doctor or a dietitian.
Long-term prevention also includes regular physical activity, maintaining a healthy weight, avoiding smoking, moderating heavy alcohol use and limiting regular NSAID use when possible.
A final word
Diverticulosis itself is often lifelong because the pouches usually remain once they have formed, but many people never develop diverticulitis. For those who do, most episodes are uncomplicated and recover with appropriate care. Recurrent or persistent disease may require longer-term medical management, and any new or severe symptoms should be evaluated by a healthcare professional.
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