Contents

DiverticulitisEdit

Diverticulitis is an inflammatory condition of colonic diverticula, most often arising in the sigmoid colon, that sits on a broader spectrum of diverticular disease. It typically occurs in people with diverticulosis, a condition in which small pouches (diverticula) form along the colon wall. Most cases are mild and can be managed without surgery, but complications such as abscess, perforation, fistula, or bowel obstruction can occur. In modern practice, the emphasis is on accurate diagnosis, appropriate use of antibiotics, and targeted care that minimizes unnecessary hospitalizations and procedures while protecting patients’ long‑term health and pocketbooks. The condition and its management are closely tied to overall digestive health, lifestyle factors, and the availability of efficient medical care.

Diverticulosis, the presence of diverticula, becomes more common with age and is particularly prevalent in populations consuming Western-style diets high in refined carbohydrates and low in fiber. The diverticula themselves are outpouchings of the colon wall, most often in the sigmoid segment, where the lumen is narrower and the wall is relatively weaker. When these outpouchings become inflamed or infected, the result is diverticulitis. Beyond age, risk factors that have been associated with diverticular disease include obesity, smoking, physical inactivity, and certain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids, which may influence inflammation and healing. The exact cause of diverticulitis is multifactorial and remains a topic of ongoing research, but the pattern is well established: a background of diverticulosis with episodic inflammation in some patients.

Causes and risk factors

  • Age and cohort patterns: risk rises with advancing years.
  • Diet and lifestyle: low fiber intake and sedentary behavior have been linked with higher incidence, while sustained physical activity appears protective.
  • Obesity and smoking: these factors correlate with greater likelihood of symptomatic disease.
  • Medications: NSAIDs, steroids, and certain other drugs may affect colonic wall integrity and inflammatory responses.
  • Anatomic location: the sigmoid colon is most commonly affected due to its narrow lumen and high intraluminal pressure.

Clinical features

  • Pain: usually steady, localized to the left lower quadrant, though orientation can vary in different people.
  • Fever and systemic signs: fever, tenderness, and sometimes mild nausea or changes in bowel habit (diarrhea or constipation).
  • Laboratory findings: mild leukocytosis is common, but blood tests are not definitive and must be interpreted with imaging.
  • Red flags: sudden severe pain, signs of sepsis, or suspected perforation require urgent evaluation.

Diagnosis

  • Imaging: computed tomography (CT) of the abdomen and pelvis with contrast is the reference standard for diagnosing diverticulitis and for identifying complications such as abscess, perforation, or obstruction.
  • Clinical assessment: history and examination guide initial management, but imaging confirms the extent and helps plan treatment.
  • Other tests: when imaging is inconclusive, ultrasound can be helpful in some settings. Colonoscopy and other endoscopic tests are typically deferred during an acute attack to avoid concern for perforation, and are scheduled after the episode resolves to assess the colon for other pathology, including colorectal cancer.

Management

Diverticulitis management aims to relieve symptoms, control infection, prevent complications, and minimize unnecessary interventions. The approach balances effectiveness with cost and patient burden, a stance echoing broader policy preferences for evidence-based, efficient care.

  • Outpatient vs inpatient care: most patients with mild, uncomplicated diverticulitis can be managed at home with clear instructions, regular follow-up, and symptomatic relief. Hospitalization is reserved for those with high fever, systemic illness, significant comorbidities, pregnancy, or signs of complications.
  • Antibiotics: traditional practice used to include antibiotics for most cases of diverticulitis. In recent guidelines and practice, there is a trend toward withholding antibiotics in carefully selected healthy patients with uncomplicated diverticulitis, relying on close observation and supportive care. When antibiotics are used, they are chosen to cover common colonic bacteria, including anaerobes and gram-negative organisms, and are typically given for a shorter course in mild cases. This approach emphasizes antibiotic stewardship and the consumption of limited medical resources where safe.
  • Pain control and hydration: analgesia and adequate fluids are central to initial management. Non-opioid analgesics are preferred when possible, with careful consideration of individual risks.
  • Diet and return to activity: after an episode begins to improve, a gradual return to regular eating is typically advised. A high-fiber diet is often recommended after recovery to support long-term colonic health, though dietary planning is individualized. It is important to reintroduce foods at a pace that suits the patient.
  • Complications and when surgery is considered: complicated diverticulitis—such as abscesses requiring drainage, perforation, obstruction, or persistent or recurrent illness despite medical therapy—may necessitate interventional radiology procedures, surgery (such as a colectomy) or, in some cases, more extensive rectal or colon procedures. Indications for surgery have evolved toward a more conservative philosophy, reserving operative intervention for those with recurrent, severe, or lifelong-derived disease, or for those with complications that cannot be resolved with medical therapy.
  • Post-attack surveillance: once the acute episode resolves, clinicians typically assess the need for colonoscopy to exclude other conditions, including colorectal cancer, especially if the patient has not had recent screening.

Prevention and lifestyle

  • Diet: maintaining a diet rich in fiber and fluids supports bowel health and can reduce the risk of future episodes for many patients.
  • Weight and activity: maintaining a healthy weight and engaging in regular physical activity are associated with better outcomes and lower recurrence in different studies.
  • Smoking cessation and moderation of alcohol intake: these are general health measures that may influence overall risk.
  • Surveillance and primary prevention: routine medical care, adherence to screening guidelines, and timely management of other health conditions contribute to reducing complications.

Controversies and debates

  • Antibiotics for uncomplicated diverticulitis: a core debate centers on whether antibiotics are always necessary for mild, uncomplicated cases. Proponents of limiting antibiotic use argue that this reduces antibiotic resistance, lowers side effects, and cuts costs, without compromising short-term outcomes in carefully selected patients. Critics worry about potential undertreatment and recurrence. The trend toward selective antibiotic use reflects a broader emphasis on evidence-based, cost-conscious care.
  • Diet and fiber with recurrence: for many years, a high-fiber diet was recommended to prevent recurrence, while some studies show mixed results. The practical takeaway is that fiber-rich patterns generally align with overall gut health, but individual responses vary.
  • Seeds, nuts, and small foods: a longstanding belief held that seeds and hulls should be avoided to prevent inflammation, but contemporary evidence does not support this restriction. Clear guidance to patients now emphasizes that there is no need to avoid nuts, seeds, or popcorn as a general rule.
  • Timing of colonoscopy after an attack: after an episode of diverticulitis, some clinicians delay colonoscopy to avoid misinterpreting inflammatory changes as cancer. The question remains about the optimal timing, with many guidelines recommending evaluation within a defined period after clinical recovery to screen for cancer and assess colon health.
  • Role of surgery in recurrent disease: there is ongoing discussion about when to operate for recurrent diverticulitis. The modern view tends toward a more conservative approach—prioritizing nonoperative management and considering surgery mainly for refractory cases or when complications arise. This stance reflects a broader policy preference for preserving function and avoiding unnecessary procedures while ensuring patient safety.

See also - diverticulosis - colon - colorectal cancer - antibiotics - surgery - dietary fiber