Diverticulosis and Diverticular Disease: who should be operated on?

Our expert in General Surgery in Avellino , Dr. Luca Covotta, explains why the diverticula are formed and what needs to be done in case of their inflammation

What are diverticula?

The diverticula are pockets that develop in the colon wall, usually in the sigmoid or left colon, but may involve the entire bowel. Their formation is due to the exhaustion of the muscle tunic through which the mucosa makes a hernia bringing it into direct contact with the serous, therefore the correct term would be “pseudodiverticula”. It is a very frequent condition, with an incidence of over 60% in Western countries after 65 years of age.

Why are they formed?

In the vast majority of cases this occurs due to an increase in blood pressure linked to constipation . The mere presence of these diverticula is no longer considered pathological especially after a certain age, so much so that there is talk of “diverticulosis” and it represents about 80% of patients with colon diverticula. This condition, it has been widely demonstrated, does not require any anti-inflammatory or antibiotic therapy, just as it is not necessary to follow special diets. In 20% of cases, however, the presence of diverticula develops a symptomatology and therefore we speak of diverticular disease , which we can further divide into:

  • 80%: Symptomatic Uncomplicated Diverticular Disease (SUDD), totally overlapping both clinically and in the treatment of irritable bowel syndrome;
  • 20%: Acute diverticulitis, characterized by acute inflammatory forms with pain in the left side and fever or major bleeding. Usually these episodes resolve with antibiotic and anti-inflammatory therapy, in some cases it requires hospitalization. Only in very rare cases (0.5%) can this condition be accompanied by a perforation of the diverticulum with consequent peritonitis and therefore emergency surgery. The episode of acute diverticulitis exposes the patient to an evolution of this condition:
    • About 80%: uncomplicated chronic diverticulitis in which the persistence of painful symptoms tends to prolong with episodes of exacerbation and alterations of the alve;
    • About 20%: complications develop related to the formation of a dangerous abscess, to a possible fistula between the colon and other nearby organs, in particular the bladder or to the narrowing of the colic tract (stenosis);
    • About 1-2%: segmental colitis associated with diverticulosis SCAD (Segmental Colitis Associated with Diverticulosis), a chronic inflammatory process located in the area of ​​the colon where the diverticula are located (generally the sigmoid) that involves the inter-diverticular mucosa usually saving the peri-diverticular mucosa.

How is the diagnosis made?

Certainly colonoscopy is the most common investigation with which the presence of colon diverticula is highlighted . As described, once the presence of the diverticula is highlighted, the various scenarios described above can be opened.

In acute forms it would certainly be better to avoid endoscopic investigation because intestinal preparation and air insufflation could increase the risk of complications. In these cases the main investigation is the Computed Tomography, which in addition to showing us the extent of the diverticular disease allows us to see the peridiverticular tissue and therefore any perforations or abscesses.

In chronic forms, the inflammatory process often induces a considerable angle and fixity to the bowel, such as to make the passage of the colonoscope impossible. Under these conditions, an opaque enema x-ray was performed once, an investigation with contrast medium from the anus, and then radiographs were taken to evaluate the progression of contrast in the colon.

Today we use a special software applied to computed tomography, called ” Virtual Colonoscopy “, in which we have a three-dimensional reconstruction of the colon using the images acquired in CT.

Who should be operated on?

In the past, the surgical indication was linked, in addition to the acute (perforation, abscess, occlusion) or chronic (stenosis, fistulas) complications of the disease, also to the number of diverticulitis attacks that a patient went through.

According to what established by “The Practice Parameters Committee of the American College of Gastroenterology”, in fact, after 2 episodes of diverticulitis it was necessary to perform a colectomy for preventive purposes. This indication was based on evidence related to the number of relapses, such as:

  • Increased risk of complications
  • Decreased response to conservative therapy;
  • Greater morbidity and mortality to which the patient was being exported, compared to emergency surgery.

Subsequent studies have in fact shown that in the majority of cases the surgical indication for perforation occurs in 90% of cases at the first diverticular attack. This fact has even suggested that there is a particular form of particularly aggressive diverticular disease that induces immediate perforation.

Furthermore, the risk of having repeated attacks of diverticulitis reduces the possibility of perforation or abscess complications, so much so that in 2006 the Standards Committee of the American Society of Colon and Rectal Surgeons published Practice parameters for sigmoid diverticulitis, stating that ” The evaluation of the indication Surgery in diverticular disease is fundamentally linked to the patient’s condition regardless of the number of episodes of previous diverticulitis, which ultimately seem to have a protective effect and certainly not a decisive effect for a prophylactic colectomy “.

That is, the decision whether to undergo surgery is not tied to certain parameters but only to the consideration of the state of alteration of the quality of life that this disease entails. Today, with the advent of laparoscopic colon surgery, the intervention in subjects whose chronic inflammatory state has significantly reduced or angled the caliber of the bowel, leading to chronic constipation, can be better recommended.


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