Diverticulitis

Anatomy

The colon is an organ at the end of the digestive tract whose main function is to absorb excess water and wastes so a person does not become dehydrated as wastes are eliminated. The colon helps thicken the consistency of waste from a watery substance to a thick or even solid paste in stool that allows safer evacuation. The colon is located around the back part of the abdomen. The intestines plug into it in the right lower quadrant of the abdomen and the colon slides up towards the right ribcage, swings over to the left ribcage, slides down the left belly wall, curves over the pelvic rim and goes down into the rectum and ultimately hooks up to the anus which is the final sphincter of the digestive tract.

Over time, the colon can have some wear and tear and produce some outpouchings of the colon wall (much like a worn out bicycle or car tire can have a weak area). This is called diverticulosis. Most adults by the time they reach retirement age have some evidence of diverticulosis. Ways to help minimize the chance of this is to have a high fiber diets and soft foods. Having diverticulosis does increase the risk of having problems with bleeding especially on the early part (right side) of the colon. The lower colon (especially in the S-shaped or sigmoid colon that is the last part of the colon that connects to the rectum) is prone to infections where the little pockets of diverticulosis can be plugged or irritated. This is called diverticulitis and results when a pouch can become irritated and burst, resulting in leaking of stool into the abdominal cavity outside the colon. Most episodes of diverticulitis are very tiny perforation tears that are well contained in the abdomen. If unchecked, the perforation can result in abscess or intestine death and worsening problems.

Classically the first treatment for diverticulitis is antibiotics. If caught early enough, patients can receive oral antibiotics (typically Ciprofloxacin and Flagyl), and usually over a couple of weeks the body heals the diverticulitis. Sometimes the infection is more pronounced and requires hospital admission with administration of IV antibiotics. Sometimes with diverticulitis the perforation can be so large that obvious contamination of air and stool into the abdomen warrants an emergency surgery.

After an attack of diverticulitis is healed without emergency surgery, elective surgery to prevent another attack maybe warranted. Younger patients who have a longer lifespan to have further attacks are often patients who wound benefit from having elective resection of areas of diverticulosis of their colon to help prevent another attack of diverticulitis. In cases of older patients, the surgical and medical literature is not as certain as to how many attacks are needed to occur before the risk of diverticulitis is greater than the risk of electrive surgery. But usually after two attacks surgery must be strongly considered to help the excise the area of colon that keeps getting infected.

Surgery can either be done through smaller laparoscopic incisions with a small incision a couple of inches long to allow the colon to be excised. In some cases where patients have had numerous prior surgeries or if it is an emergency surgery an open incision typically from the belly button down to the top of the pelvic bone is needed to help have adequate exposure to get the colon out.

Surgery involves the patient having to go under complete general anesthesia to be entirely asleep. They are positioned often in stirrups and the abdomen is prepped sterilely. Appropriate incisions are made and the colon is freed from its attachments to the belly wall and its blood supply is taken with stitches or staples. The diseased area of colon is removed usually giving an inch or two of normal colon as a safe margin on either side of the diseased portion. The colon is reattached together using staples and/or stitches and the diseased colon is sent to pathology for further review. The surgery itself usually takes a couple of hours and requires a hospitalization of several days up to a couple of weeks depending on if the surgery is an emergency surgery or an elective surgery.

There are risks to surgery including bleeding, wound infection, abscess, and leak. Despite all efforts to use stitches and staples to carefully bring the tissues together, sometimes the tissues will not heal properly and stool can leak around the new anastomosis. This can happen 2-5% of the time. This risk can increase in situations of emergency surgery with infection; severe malnutrition, diabetes, smoking (which decreases the amount of oxygen that can help the tissues heal), or being immunosuppressed from medications or health conditions.

Consultation with a medical physician is essential and often a gastroenterologist needs to be involved as well. A complete colonoscopy prior to surgery is extremely important to rule out that there is no other source of pain and perforation such as a cancer or a bleeding lesion that could also explain pain, perforation, or bleeding.

Colon surgery can be performed by any the surgeons at Regional Surgical Specialists. If you have any questions or concerns please contact us at 828-252-3366.