In the past, having several bouts of diverticulitis—a painful condition characterized by pea-size pouches (diverticula) that form in weakened areas of the colon wall and become infected or inflamed—might have landed you in the operating room. These days, experts recommend a more conservative diverticulitis treatment approach for most cases. Yet, a new study suggests that too many doctors are still turning to a surgical solution, putting many patients through needless procedures and potential risks.
“It seems that far too many surgeries for uncomplicated diverticulitis are being performed without an appropriate indication,” says Joseph H. Sellin, M.D., a professor of medicine at Baylor College of Medicine and director of gastroenterology at Ben Taub General Hospital in Houston. “Most national surgical societies have updated their guidelines to avoid unnecessary elective surgeries for early diverticulitis, but many doctors continue to perform surgery, and we’re not quite sure why.”
What is diverticulitis?
Diverticula develop in most people as they age, causing a condition called diverticulosis, which is often symptomless. Most people don’t know they have diverticulosis until it’s discovered by accident during an exam, such as a barium enema, sigmoidoscopy, colonoscopy, or a computed tomography scan for another gastrointestinal ailment. The condition is present in about half of Americans over age 60. The American Society of Colon and Rectal Surgeons (ASCRS) estimates that about 20 percent of those with diverticulosis eventually develop diverticulitis.
Unlike diverticulosis, diverticulitis makes its presence known. The most common symptom of a flare-up is abdominal pain or tenderness, usually on the left side. The pain can be severe and fluctuate in intensity. It can occur with cramping, nausea, vomiting, chills, fever, pain with a bowel movement, loose stool, and occasional scant amounts of blood.
Simple or complicated?
Most cases of diverticulitis are designated as simple, or uncomplicated. Complications arise in 25 percent of patients and can include an abscess (a collection of pus surrounded by inflamed tissue) or a fistula (an abnormal connection between the colon and an adjacent organ such as the bladder, small intestine, vagina, or skin).
Mild, uncomplicated diverticulitis is treated at home with bed rest, a clear-liquid diet to rest the colon, and acetaminophen (such as Tylenol) for pain relief. Oral antibiotics are sometimes pre- scribed, although there’s little evidence that they aid in recovery or prevent complications or future flare-ups. Most patients feel better in two to three days. Signs that patients aren’t improving and may need to be hospitalized or examined for complications are an inability to tolerate liquids, a fever, and increasing pain.
People who have moderate to severe uncomplicated diverticulitis or acute pain may be hospitalized to be treated with intravenous antibiotics as well as fed intravenously to allow their colon to recover. Hospitalization depends on whether a patient has one or more other chronic conditions and his or her overall health. Once your attack of diverticulitis has subsided, your doctor may want to perform a colonoscopy to rule out any complicating factors, such as colon cancer.
Overuse of surgery
For years, elective surgery to prevent subsequent episodes of acute uncomplicated diverticulitis was common. The surgery, called bowel resection, involves removing the diseased portion of the colon and reattaching the remaining sections. Surgery is performed as either a minimally invasive (laparoscopic) procedure or an open resection, based on the patient’s condition and the surgeon’s skills.
Over the past decade, mounting medical evidence showed that recurrences are less frequent and often less severe than once believed—especially in individuals 50 and older. Experts have backed away from suggesting surgery for acute uncomplicated diverticulitis. An important question now is whether doctors are heeding the advice to avoid the scalpel in favor of noninvasive treatments.
The answer is no, say researchers from the University of Washington, Swedish Medical Center of Seattle, and Virginia Mason Medical Center in Seattle. They examined four years’ worth of private insurance claims to determine how many adults up to age 64 with only one or two episodes of uncomplicated diverticulitis had undergone surgery to remove the weakened trouble spots in their colon. They reported their results online in February in JAMA Surgery.
The researchers analyzed 3,054 insurance records of people who had surgery for uncomplicated diverticulitis. They found that 56 percent of those patients were operated on before they’d had a third flare-up—a threshold experts once used to decide when surgery was warranted.
The ASCRS updated its guidelines in 2014 and now discourages surgery after an initial episode of uncomplicated diverticulitis. Instead, it suggests that surgical decisions be made on a case-by-case basis. Clinical recommendations from the American Gastroenterological Association (AGA) echo the same approach.
Surgery is often needed in cases of complicated diverticulitis, for example, to remove a fistula and the affected part of the colon, drain an abscess, or treat patients with an infection.
Certain patients with uncomplicated diverticulitis may be considered for elective surgery, including people for whom medical management has proved unsuccessful such as those undergoing chemotherapy or who have had an organ transplant. About 1.5 percent of people with diverticulitis often require surgery because they have “right-sided” diverticulitis instead of the more common left-sided disease.
If you have uncomplicated diverticulitis and your doctor suggests surgery, ask him or her to explain why a surgical procedure might be right for you. The ASCRS suggests that you ask your doctor or surgeon these additional questions:
• How severe is my case?
• What are success rates and risks of surgical and nonsurgical treatments?
• What can I expect after surgery?
• How will my pain be managed?
• What are the risks if my diverticulitis isn’t treated?
Be sure to ask your surgeon about the surgical risks involved. According to the AGA, about 10 percent of people who have surgery after an acute episode experience brief complications such as infection, leaking from the colon, heart problems, or blood clots. These short-term risks can be more pronounced in older adults. Twenty-five percent of all patients have long-term complications, including a distended abdomen, cramping, changes in bowel movements, or fecal incontinence following elective surgery.
“It’s important to have a thoughtful conversation with your doctor about which treatment will do the most long- term good and least harm,” says Dr. Sellin. “Take into account any anxiety you have about future episodes or how diverticulitis will affect your quality of life. Getting a second opinion helps, too.”
Warning signs of complications
If you’re undergoing treatment for uncomplicated diverticulitis and experience any of the following symptoms, contact your doctor immediately:
• A fever of 100°F or more that doesn’t go away
• Nausea or vomiting
• Worsening pain
• Red or maroon-colored blood in the stool, which may be a sign of diverticular bleeding