Introduction
Small bulging sac-like pouches that develop in the lining of the lower digestive system are referred to as diverticula. The exact cause is unknown; however, it may be attributed to a decreased fiber intake. Diverticular disease of the intestine affects mainly the elderly; the incidence rises with age and is commonly seen in men, especially people 80 years and above. The diagnosis and management may be quite challenging owing to the comorbid conditions in elderly people.
What Is Colonic Diverticulitis?
The bubble-like structures or expanded areas, which range from pea size to much larger, form when the pressure in the colon increases, leading to the formation of pockets in the weakened areas of the colon, especially the lower left side inner wall of the intestine. These diverticula may sometimes get inflamed and infected, which is called colonic diverticulitis. These bulges may form throughout the colon; the most affected is the sigmoid colon, closest to the rectum. Colonic diverticulitis can be classified as acute and chronic diverticulitis. Acute uncomplicated diverticulitis is the most common form, with around 75 to 80 percent of cases. Complications such as abscess (a pus-filled pouch), fistula (an uncommon connection between two different structures or organs), or perforation of the diverticula can develop and lead to acute complicated diverticulitis, seen in about 15 percent of cases.
When acute diverticulitis fails to heal, it results in chronic diverticulitis. When the thickness of the colonic wall is well-defined, or mucosal inflammation is observed, with the absence of stricture, it is called chronic uncomplicated diverticulitis. An acute colon obstruction or a fistula formation in the bladder, along with stenotic disease (valvular heart disease), is called chronic complicated diverticulitis.
What Are the Causes of Colonic Diverticulitis?
The exact cause of diverticulitis is unknown and may vary among patients. However, studies suggest that micro or macro perforation (tear) in the diverticula may cause the release of bacteria, resulting in inflammation. Acute diverticulitis is associated with more inflammation rather than infection. Cytomegalovirus may trigger inflammation in over two-thirds of patients with diverticulitis. Consumption of a low-fiber diet or processed foods can cause constipation and hard stools, leading to strain during passing stools which increase the pressure in the colon, leading to the formation of diverticula.
What Are the Signs and Symptoms of Colonic Diverticulitis?
Signs and symptoms of colonic diverticulitis are more severe and usually have a sudden onset. These include:
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Constant pain lasts for several days, usually on the lower left side of the abdomen. However, right-sided pain may occur on right colon involvement.
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Fever and chills.
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Nausea and vomiting.
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Bloating sensation.
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Decreased appetite.
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Constipation or change in bowel habits.
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Abdominal distension, tenderness, cramps, and sensitivity.
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Rectal bleeding.
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Bladder pain, fecaluria (appearance of feces in urine), and pneumaturia (air bubbles in urine) may be seen due to fistula formation in acute complicated diverticulitis.
What Are the Risk Factors of Colonic Diverticulitis?
Risk factors of colonic diverticulitis include:
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Age and overweight.
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Consumption of low fiber diet.
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Consumption of a fat-rich diet or red meat.
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Lack of physical activities or exercises.
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Corticosteroids, non-steroidal anti-inflammatory drugs such as Aspirin, Ibuprofen, Naproxen, etc.
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Patients suffering from human immunodeficiency virus (HIV) infections or patients undergoing chemotherapy are prone to developing acute diverticulitis.
What Are the Complications of Colonic Diverticulitis?
Colonic diverticulitis requires appropriate diagnosis and management; otherwise, it can result in complications such as:
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Bleeding from the diverticula.
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Perforation or a tear in the colon.
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Infection of the diverticula can lead to a fistula or abscess formation.
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Narrowing of the area in the colon (stricture).
How Can Colonic Diverticulitis Be Managed in Older People?
The management of colonic diverticulitis depends on the severity of the symptoms. Most of the mild to moderate cases are treated through medications, and severe cases may require surgical intervention.
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In case of mild colonic diverticulitis, the doctor may advise oral antibiotics such as Metronidazole, Ciprofloxacin, Amoxicillin with Clavulanic acid, Trimethoprim-Sulfamethoxazole, etc. Taking over-the-counter (OTC) medications for pain must be avoided.
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Bed rest is advised, along with analgesics, to relieve pain and fever.
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Liquid or a bland diet may be recommended until the symptoms subside. A soft to normal diet can be gradually started when the symptoms improve, along with fiber-rich foods. Symptoms usually subside with these steps in mild cases.
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Intravenous antibiotics and fluids may be initiated in severe cases of colonic diverticulitis, and surgery may be indicated in cases of recurrence of symptoms post-management.
When Is Surgery Indicated in the Management of Colonic Diverticulitis?
Surgery is recommended for the following conditions of colonic diverticulitis:
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Rectal Bleeding: When a small blood vessel near a diverticula bursts, it can result in bleeding. If measures such as clipping, cauterizing, or medications fail to stop bleeding, surgery may be indicated.
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Recurrence: The diseased portion of the colon may be surgically removed in some cases of multiple recurrences of diverticulitis; however, diet modifications or the condition does not respond to other treatment modalities.
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Abscess Formation: Fluid-filled cavities with bacterial cells, which cannot be drained with a needle or catheter, need to be surgically treated and cleaned.
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Fistula Formation: An abnormal connection between different parts of the colon or between the colon and another part of the body, such as the skin, uterus, bladder, vagina, etc., cannot be treated conservatively and requires surgical management.
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Perforation: Tearing of the affected area of the colon causes the pus to leak into the abdominal cavity, which is an emergency. Surgery needs to be performed, and the damaged part of the colon must be removed to prevent further complications.
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Strictures: Complete blockage of a section of a colon due to previous infections can result in scars and partial or complete blockage or narrowing of the sections of the colon.
How Is Colonic Diverticulitis Managed Surgically?
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During the surgery of colonic diverticulitis, a part of the diseased colon is removed, and the colon is reattached to the rectum. Depending on the severity, the surgical technique is determined.
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Endoscopic ultrasound-guided drainage or computed tomography (CT) guided percutaneous drainage is recommended for multiloculated inaccessible, large abscesses (more than three centimeters) or in case of abscesses that do not respond to antibiotics or drainage. The minute abscess can be treated by broad-spectrum antibiotics and bed rest.
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Surgery is immediately required for patients with perforation or severe symptoms such as intense pain, fever, and tenderness or who fail to respond to all other treatment methods. In the case of complicated diverticulitis, persisting abscesses or fistulas may indicate surgical resection.
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The affected part of the colon is resected, and the ends are anastomosed (a procedure where the connection between two open structures is done) in patients without perforation or abscess. In other cases, temporary colostomy with anastomosis may be carried out after the resolution of the inflammation, which may help improve the patient's condition.
How Can Colonic Diverticulitis Be Prevented?
Colonic diverticulitis can be prevented by the following methods:
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Including more fiber in the diet, like green leafy vegetables, fresh fruits, and cereals, softens the stools and prevents constipation.
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Adequate intake of fluids keeps the body hydrated, maintains weight, and facilitates bowel movement.
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Regular physical activities and exercises help in the digestion of food and prevent bloating, constipation, and the development of diverticulitis.
Conclusion
Inflammation or infection of the diverticula is referred to as colonic diverticulitis. It affects mostly elderly people and is associated with severe pain, fever, constipation, nausea, vomiting, etc. Mild and uncomplicated diverticulitis can be managed by antibiotics, adequate rest, and diet modifications. However, severe and complicated cases require surgical intervention. Maintaining a healthy lifestyle by consuming a high-fiber diet, having adequate fluids, and doing physical exercises can help prevent colonic diverticulitis.
