Acute diverticulitis occurs when small, bulging pouches (diverticula) in the wall of the large intestine become inflamed or infected. While diverticula are common, especially with age, they typically do not cause issues. However, inflammation or infection can lead to symptoms such as abdominal pain, fever, and changes in bowel habits. The severity of acute diverticulitis can range from mild to severe, and treatment approaches are tailored accordingly.
Conservative Management
Initial treatment for acute diverticulitis often involves conservative, non-surgical methods, especially for mild cases without complications. Bowel rest, typically beginning with a clear liquid diet, is a crucial aspect of this management. This diet includes water, broth, clear juices without pulp, gelatin, and tea without milk, aiming to reduce stimulation of the inflamed colon.
As symptoms improve, usually within two to three days, a gradual transition to a low-fiber diet is recommended. This approach helps the digestive tract heal by limiting residue. Foods such as refined white bread, white rice, cooked vegetables without skin, and lean proteins are commonly included. After the acute episode resolves, which usually takes one to two weeks, patients are advised to slowly reintroduce a high-fiber diet, along with adequate hydration, to promote regular bowel movements and help prevent future flare-ups.
Antibiotics play a role in managing infection, though their routine use for uncomplicated cases is being re-evaluated. When prescribed, oral antibiotics like ciprofloxacin and metronidazole, or amoxicillin-clavulanate, are common for outpatient treatment. For more severe cases requiring hospitalization, intravenous antibiotics such as piperacillin/tazobactam or ciprofloxacin with metronidazole are administered. Antibiotic therapy typically continues for 10 to 14 days, with a transition from intravenous to oral forms once symptoms improve and the patient can tolerate oral intake.
Pain management primarily involves acetaminophen (Tylenol), which is preferred due to its ability to reduce pain and fever without irritating the gastrointestinal tract. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen should be avoided as they can increase the risk of gastrointestinal bleeding and potentially worsen inflammation. For more intense pain, short-term use of opioid medications may be considered, though these are used cautiously due to potential side effects like constipation. Maintaining proper hydration with intravenous fluids can be important, especially for hospitalized patients, to support recovery and overall well-being.
Indications for Surgical Intervention
While many cases of acute diverticulitis respond to conservative management, surgery is indicated for complications that pose a significant threat to health. These include perforation of the colon, where a tear allows contents to leak into the abdominal cavity, leading to peritonitis (severe infection and inflammation of the abdominal lining). Generalized peritonitis, particularly with fecal contamination, is an absolute indication for immediate surgery.
Other complications requiring surgical consideration include abscesses (pockets of pus). If an abscess cannot be effectively drained percutaneously or recurs despite drainage, surgical removal may be necessary. Fistula formation, an abnormal connection between the bowel and another organ, typically requires surgery. Intestinal obstruction, where the passage of stool is blocked, or severe, persistent bleeding can necessitate surgical intervention.
Surgery may also be considered when conservative medical treatments fail, with persistent infection, pain, or worsening symptoms despite appropriate care. Severe presentations or high-risk features, such as uncontrolled sepsis or an immunosuppressed state, might lead directly to surgical management. Recurrent episodes of acute diverticulitis that cause significant symptoms or severely impact quality of life can also be a reason for elective surgery.
Surgical Procedures
Several surgical procedures are available to remove the diseased segment of the colon and restore normal bowel function. The most common surgical approach is a colectomy, often a sigmoid colectomy, which removes the affected part of the sigmoid colon. This can be performed using traditional open surgery (larger incision) or minimally invasive laparoscopic techniques (small incisions and specialized instruments).
Resection and primary anastomosis is a common procedure where the inflamed colon is removed and the remaining healthy ends are reconnected, allowing for continuous bowel function. This can often be achieved laparoscopically, which typically results in less pain and a quicker recovery compared to open surgery.
For severe cases, especially with significant infection or peritonitis, a Hartmann’s procedure may be performed. This involves removing the diseased colon segment and sealing off the remaining rectal stump. The healthy end of the colon is then brought out through an abdominal wall opening, creating a temporary colostomy that collects stool in an external bag. This allows the colon to heal without immediate anastomotic leak risk, and the colostomy is usually reversed in a subsequent surgery after several months.
Laparoscopic peritoneal lavage is a less common technique that involves washing out the abdominal cavity to remove pus and infection without immediately resecting the colon. While its use for widespread peritonitis is debated, it has shown promise in selected cases, potentially avoiding a colostomy. Percutaneous drainage, a non-surgical procedure, is often used to drain larger abscesses under imaging guidance, which can sometimes resolve the infection and prevent the need for immediate surgical resection.