Diverticulitis is a common digestive condition that occurs when small, bulging pouches (diverticula) in the lining of the colon become inflamed or infected. While many people develop these pouches (diverticulosis), only a minority experience the pain and symptoms of diverticulitis. Most acute episodes are managed non-surgically, allowing inflammation to subside with conservative measures. Surgery is typically reserved for severe, life-threatening complications or for chronic disease that significantly diminishes a person’s quality of life.
Initial Management of Acute Diverticulitis
When a patient experiences an acute, uncomplicated flare-up, initial treatment focuses on resting the colon and controlling symptoms. For mild cases, this often involves outpatient management with a temporary clear liquid diet and oral pain medication. The diet is gradually advanced back to solid foods as symptoms improve, typically within a few days.
Current clinical practice for uncomplicated cases in healthy individuals often avoids the routine use of antibiotics, as they may not provide additional benefit. However, patients who are immunocompromised, have severe symptoms, or exhibit specific abnormalities on imaging are usually treated with antibiotics. This often requires a short hospital stay for intravenous fluids and close monitoring.
Critical Conditions Requiring Emergency Surgery
Immediate surgical intervention is necessary when the infection progresses to a life-threatening complication requiring urgent source control. The most common emergency indication is perforation, where the infected diverticulum bursts, releasing intestinal contents into the abdominal cavity. If this leads to widespread contamination and inflammation (peritonitis), surgery is required without delay to wash out the abdomen and remove the source of infection.
Another severe complication necessitating emergency surgery is uncontrolled septic shock, which occurs when the body’s response to the infection overwhelms its ability to maintain normal organ function. This widespread infection is often resistant to initial intravenous antibiotic treatment and fluid resuscitation, signaling a failure of non-operative care. Similarly, a large abscess (greater than four to five centimeters) may require operative drainage if it is inaccessible or fails to resolve with percutaneous drainage.
Intractable bowel obstruction is a further indication, occurring when inflammation or scar tissue completely blocks the passage of waste through the colon. Severe, persistent bleeding from the diverticula that cannot be stopped through endoscopic or radiological procedures can also necessitate immediate surgery to remove the hemorrhaging segment. In all emergent scenarios, the goal of surgery is to stabilize the patient by removing the diseased tissue and controlling the contamination immediately.
Criteria for Planned (Elective) Surgery
For patients who recover from an acute episode but continue to struggle with diverticulitis, elective surgery may be recommended to prevent future complications and improve daily life. Historically, elective resection followed two or more documented episodes, though this guideline is now individualized based on the patient’s overall health and symptoms. Younger patients (especially those under 50) or those with compromised immune systems may be considered for surgery after only a single severe episode due to their increased risk of recurrence.
Elective surgery is also indicated to resolve chronic structural complications. This includes the formation of a fistula, an abnormal channel connecting the colon to an adjacent organ, often the bladder, causing recurrent urinary tract infections. Another complication is a stricture, a narrowing of the colon caused by repeated inflammation and scarring, which can lead to partial bowel obstruction and chronic symptoms.
Surgery is sometimes performed when a chronic inflammatory mass is present and physicians cannot definitively rule out colon cancer, even after colonoscopy and imaging. Removing the segment of the colon serves as both treatment for diverticulitis and a necessary step for definitive diagnosis. The procedure is typically scheduled several weeks after the inflammation has subsided to reduce surgical risks.
Surgical Options for Diverticulitis
The standard operation for diverticulitis is a segmental colectomy, often called a sigmoid colectomy, where the diseased part of the large intestine is removed. This procedure can be performed using traditional open surgery or minimally invasive laparoscopic techniques. The surgeon removes the scarred and inflamed section of the colon, ensuring healthy margins of the bowel remain.
Once the diseased segment is removed, the remaining healthy ends of the colon must be managed. In an elective setting or less severe emergency cases, the two ends are typically reconnected immediately via primary anastomosis. This restores intestinal continuity, meaning the patient avoids the need for a temporary stoma.
In emergency situations involving high infection or severe contamination, the surgeon may perform a Hartmann’s procedure. This involves removing the diseased segment, closing the distal end (rectum), and diverting the proximal end of the colon through an opening in the abdominal wall, creating a temporary ostomy (stoma). This temporary diversion allows inflamed tissues to heal before a second surgery is performed months later to reverse the ostomy and reconnect the bowel.