Diverticulitis is a painful condition that develops when small, bulging pouches in the colon wall, known as diverticula, become inflamed or infected. While an acute episode is usually treated with rest and medication, the underlying condition, diverticulosis, is chronic and often leads to frustrating recurrences. Recurrence involves a combination of residual physical damage within the colon and external lifestyle factors that promote renewed flare-ups.
Structural Changes that Promote Future Episodes
Recurrence is frequently promoted by internal, physiological changes that remain after the initial symptoms have subsided. Even following successful treatment, low-grade inflammation can persist in the colon wall, making the tissue more susceptible to subsequent attacks. This inflammatory state contributes to the ongoing irritation of the diverticula and surrounding tissue.
Repeated bouts of inflammation cause the colon wall to thicken and stiffen, a process known as fibrosis and scarring. The formation of scar tissue narrows the passageway, sometimes creating a stricture. This narrowing increases pressure within the colon and makes it easier for stool or bacteria to get trapped in the diverticula. This structural change creates an environment where new inflammation is more likely to take hold, feeding a cycle of damage and recurrence.
The balance of gut bacteria, known as the microbiome, is often disrupted, a condition called dysbiosis. This imbalance can be worsened by the broad-spectrum antibiotics used to treat acute diverticulitis, which eliminate both harmful and beneficial bacteria. An altered microbial community contributes to chronic inflammation and compromises the protective barrier of the colon lining, increasing the risk of future flare-ups.
Modifiable Daily Habits That Increase Risk
External factors and daily habits play a large part in triggering acute episodes within a structurally weakened colon. A diet low in fiber is a long-standing risk factor, as reduced bulk in the stool increases pressure within the colon, which can aggravate the existing diverticula. Conversely, a high intake of dietary fiber, particularly from fruits and cereals, is associated with a reduced risk of diverticular disease.
Consuming high amounts of red and processed meat is linked to an increased risk of diverticulitis, while a vegetarian diet may be protective. This association is related to the pro-inflammatory effects of these foods and their impact on the gut microbiome. Contrary to older advice, current research suggests that consuming nuts, seeds, and popcorn does not increase the risk of recurrence and these foods can be safely included in the diet.
Obesity, particularly excess abdominal fat, and a lack of regular physical activity raise the risk of recurrence. This is due to increased systemic inflammation and higher intra-abdominal pressure, which puts additional strain on the colon walls. Engaging in vigorous physical activity, such as brisk walking or jogging for about two hours weekly, is associated with a lower incidence of the disease.
Smoking is a significant modifiable factor that increases the likelihood of recurrence by promoting inflammation and compromising blood flow to the bowel. The frequent use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen, has also been linked to an increased risk of complications and recurrence. These medications can irritate the gut lining, making the colon more vulnerable to damage and inflammation.
Medical Approaches to Preventing Reoccurrence
Medical management of chronic diverticular disease focuses on surveillance, reducing inflammation, and surgical intervention. Following an initial episode, a colonoscopy is often recommended to rule out other serious conditions that mimic symptoms, such as colorectal cancer, and to assess the extent of diverticulosis. This surveillance is particularly important after a complicated first attack or if the patient is relatively young.
Pharmacological treatments are used to manage the underlying chronic inflammation associated with the condition. Medications like mesalamine, typically used for inflammatory bowel disease, have been explored for their anti-inflammatory effects to reduce recurrence, though its effectiveness is still debated. The non-absorbable antibiotic rifaximin, often combined with a high-fiber regimen, has shown success in reducing the rate of recurrence in certain patients.
Surgery, typically an elective colectomy to remove the affected segment of the colon, is reserved for specific circumstances to prevent severe recurrence. The procedure is considered when a patient experiences frequent, debilitating attacks that significantly impact their quality of life. Surgery is also necessary to manage severe complications, such as a persistent stricture, a fistula connecting the colon to another organ, or an unresolving abscess.