"Well, I guess we outwitted them," the 76-year-old English professor said when he came in for his periodic exam. By "them" he meant my surgical colleagues who, six years earlier, had advised the removal of a significant portion of his bowel, following his third bout with diverticulitis.
Diverticulitis is the inflammation and infection of one or more diverticula, small outpouchings—often called pockets or tics—in the walls of the descending or left colon of nearly half the population by age 60 and up to two-thirds of people older than 85.
Bowel surgery used to be the recommendation for patients who'd had a third (some said second) attack of diverticulitis.
The reasoning behind such draconian measures was the possibility that successive attacks would result in complications such as colonic abscess, or bowel obstruction or perforation producing widespread infection and, possibly, death. This could create the need for emergency surgery on a desperately sick patient, a more hazardous situation than an elective procedure.
Then, however, reports began to emerge that such fears might be unwarranted. A 2005 Mayo Clinic study showed that, although about 47 percent of diverticulitis patients had recurrent attacks, 53 percent had complications during their first episode, so surgery would not have helped. More recently, 2015 research found that recurrences didn't increase the risk of complications. Nor did complications lead to more recurrences.
Spot Signs and Symptoms
Diverticulosis (which is simply the presence of diverticula) exists without symptoms in well above 90 percent of those who have the condition. The tics may be caused by increased pressure at weak points in the bowel wall.
A microscopic perforation in the wall of a diverticulum may jump-start an infection. The body's defenses wall off that minuscule opening to prevent bacteria-laden stool from seeping into the surrounding area. We call the resulting inflammation or infection diverticulitis.
An attack of diverticulitis usually starts as a dull ache in the left lower quadrant of the abdomen (or in the right lower quadrant for most Asians). It progresses slowly over the course of a few days to pain accompanied by a fever of no more than 101° F. Constipation is common, but so are nausea and vomiting.
The diagnosis is confirmed, if necessary, by an elevated white blood cell count (indicating bacterial infection) and C-reactive protein (indicating inflammation), plus an imaging procedure—usually a CT scan of the abdomen and pelvis.
The Latest Treatment
The high prevalence of diverticulitis in Western civilization, in contrast to its low prevalence in underdeveloped countries, has been blamed by some on our dearth of dietary fiber. Based on that reasoning, high-fiber diets have become a major part of the effort to prevent recurrences of infection following an initial attack.
The once-common idea that nuts, popcorn, and seeds cause attacks has been cast aside, and their innocence has been well-documented by studies.
A seven- to 10-day course of antibiotics as an outpatient is the usual treatment, although the use of antibiotics, especially in mild cases, has never been shown by well-controlled studies to affect outcome.
Hospitalization is required only for those who are very sick or very old, or who have coexisting chronic diseases, such as diabetes, or complications (abscess, fistula, obstruction, or perforation).
A colonoscopy should never be done during an attack of diverticulitis, for fear of bowel perforation. But it should be considered about six weeks afterward to rule out colon cancer; discuss with your doctor what's appropriate for you.
A Healthier Outcome
At about the time our English professor was facing the possibility of surgery, reports began surfacing about two medications that might help prevent recurrences: mesalamine, used for ulcerative colitis, and rifaximin, an antibiotic.
Our professor began to take both (but soon gave up on the rifaximin because of its high cost). He also switched to a high-fiber diet and exercised, and was able to avoid serious surgery, either as a result of the lifestyle strategies and the medication or simply because of good fortune. Either way, he remains one happy individual.
Editor's Note: This article also appeared in the April 2018 issue of Consumer Reports On Health.
