Management of Diverticular Disease

The intestine is divided into the large and small intestine. The large intestine absorbs water from the food and fluids you eat and pushes the remaining undigested waste towards the anus. High fibrous foods like fruits and vegetables soften the undigested material and help in easy movement of stools. However, low-fibre foods can produce small and hard stools that are expelled with increased strain while passing. This straining can create weak spots in the wall of the intestine leading to conditions that cause the development of small sacs or pouches.

Diverticulosis

Diverticulosis is a condition where a large number of small pouches, known as diverticula, develop in the lining of the bowel. They can be small or large and are formed with increased strain during bowel movements, or when gas, waste, or liquid put pressure on the weak portions of the walls of the intestine. This is a common condition that can be found in 10% of people above age 40 and 50% of people over the age of 60.

Diverticular Bleeding

Diverticular bleeding occurs when there is an injury to the blood vessels lying adjacent to the diverticula.

Diverticulitis

Inflammation and infection of the diverticula is known as diverticulitis. When waste material blocks the diverticula, they can become inflamed due to bacterial invasion. Increased pressure on the colon wall or a block at the entrance of the diverticula can reduce blood supply and lead to infection and inflammation.

Signs & Symptoms

People suffering from diverticulosis do not have any serious symptoms, but when infection or inflammation occurs, the symptoms can be sudden in onset.

Diverticulitis symptoms include:

• Abdominal pain and tenderness in the left lower abdomen
• Bleeding from the rectum
• Abdominal bloating
• Nausea and vomiting
• Fever and chills

Diverticular diseases can lead to other complications such as:

• Peritonitis: rupture of diverticula and leakage of intestinal contents into abdominal cavity
• Blockage in colon or small intestine due to scarring
• Abscess formed by collection of pus
• Fistula: Abnormal passage between intestine and abdominal wall or intestine and bladder or vagina.

Diagnosis

As people with diverticulosis show no symptoms, diagnosis usually occurs during routine screening examinations such as colorectal cancer screening or other intestinal tests.
When you present with symptoms of diverticulitis, your doctor will examine your medical history with relation to your diet, bowel habits, and current medications and will perform a physical examination. He/she may also conduct a digital rectal examination, where a gloved and lubricated finger is inserted into your rectum to check for abnormalities. The following diagnostic tests may be ordered to determine the extent of damage to your intestine:

• Sigmoidoscopy: A flexible tube with a camera fitted at one end (sigmoidoscope) is introduced through the anus to visualise the inner lining of the sigmoid colon (lower 1/3rd of the colon) and rectum.
• Colonoscopy: A flexible tube with a camera fitted at one end (colonoscope) is introduced through the anus to visualise the entire large intestine.
• Blood tests: A sample of your blood is analysed in the laboratory for infection.
• Imaging tests such as X-rays, ultrasound and CT scans
• Angiography may also be required to identify the site of bleeding if you have heavy rectal bleeding. Angiography is a procedure performed to visualise blood vessels after injecting a contrast material into the arteries.

Treatment

Treatment for diverticular diseases depends on the severity of symptoms. People showing no symptoms of diverticular disease are encouraged to exercise regularly and eat a high-fibre diet to avoid constipation and increased stress on the bowel wall. Your doctor may prescribe medication for pain and antibiotics for infections.

In patients with recurrent episodes of diverticulitis, leading to complications such as abscess, perforation, or fistula, surgical treatment may be recommended. Surgery involves removing the diseased section of your colon. There are two types of surgery:

Primary Bowel Resection: During this procedure, the affected portion of your intestine is removed and the healthy ends are reattached using a procedure known as anastomosis. Depending on the extent of damage to your intestine, primary bowel resection can be performed laparoscopically or using an open surgery technique.

• Open Colectomy

  An open colectomy uses a single large incision approximately 15 – 25 cms down the center of the abdomen through the abdominal wall. The diseased section of bowel will then be removed through the incision. The two cut ends of bowel will be sewn together. Some soft tubes may be left in the abdomen to drain any accumulating fluids. Stitches or staples will be used to close the wound. A dressing will be placed over the incisions. With open colectomy, the recovery period in the hospital is usually, but not always, longer the laparoscopic procedure being between 5-7 days. This was the standard operation in the past and although minimally invasive laparoscopic surgical techniques have largely superseded the open procedure it may still be advised and performed in some cases.

• Laparoscopic Colectomy

  Colectomy can also be performed using laparoscopic (keyhole) surgery. The surgeon will use a slender instrument (laparoscope), which is inserted through tiny incisions (cuts) in the abdomen. This eliminates the need for an abdominal incision.

  Occasionally an operation that starts out as a laparoscopic colectomy turns into open surgery if the surgeon encounters unexpected difficulties.

The advantage of primary bowel resection is that you will be able to have normal bowel movements after the surgery.

Bowel Resection with Colostomy: In cases where the bowel is significantly diseased and inflammation and infection widespread, your doctor may perform bowel resection with colostomy. During a colostomy, your doctor will create a surgical opening (stoma) in your abdominal wall and join the healthy part of your bowel to the skin creating a stoma. Waste from the colon flows through the stoma into a collecting bag (colostomy bag) attached to the stoma. Your surgeon may be able to perform another surgery later to re-join your colon and rectum once the inflammation has healed.