On this episode of Kentucky Health, Dr. Wayne Tuckson welcomes Dr. Sandra Kavalukas, a colorectal surgeon with UofL Health, to discuss diagnosing and treating diverticular disease.
Causes and Complications of a Common Gastrointestinal Disease
Kavalukas classifies diverticulosis as a anatomic problem that is distinct from ulcerative colitis and Crohn’s disease. It occurs when small pouches called diverticula form and then bulge out of the walls in the digestive tract, mainly in the colon. The condition is benign and does not cause problems unless the diverticula become infected and inflamed, which results in a disease called diverticulitis.
“That will lead to a large abscess, and sometimes that will lead to an irregular connection to nearby structures and cause ongoing inflammation,” she explains. “Pretty soon you have contents of the colon that make their way into other places where they’re not supposed to be.”
Incidence rates and hospitalizations for diverticular disease have increased over the past decade, Kavalukas says. Americans are at a higher risk of developing diverticula, especially people over age 50, since diverticula increase in number over time. Kavalukas points out that countries that are becoming more industrialized, such as China, are also seeing increasing incidence rates of the condition.
“There have also been a lot of studies showing that the diet may have something to do with the causation of diverticula,” she says. “So if you (follow) a diet that is not very high in fiber or is high in red meat – what they call a ‘Western diet’ – it typically has higher incidences of diverticula in the colon than other diets across the globe.”
Kavalukas notes that these studies have targeted the microbiome as the breeding ground for harmful bacteria that can cause diverticula to form. Diverticulosis is more common in the left side of the colon (known as the sigmoid colon) closer to the rectum. That’s because stool forming in the colon is more solid by the time it reaches the sigmoid colon, requiring more muscular effort to propel it forward, which can then cause the tissue to breach the colon walls.
Complications from diverticulitis begin with inflammation in the affected area but also outside of the colon, Kavalukas says.
“There’s lots of things that live around the colon – the small intestine, the bladder, in women the uterus and vagina are in that area, you have tubes between your kidneys and bladder – everything is around your colon,” she explains. “So that inflammation can pass on to those structures. And over time, (tissue) can form a little shortcut between those structures that is not supposed to exist.”
This abnormal growth, called a fistula, can lead to the movement of fluid and waste from one organ to another and usually require surgery to repair. Diverticulosis can also cause an abscess to form in the colon that will need to be drained.
“The other thing that is more common than you would imagine is a lot of people might not recognize that they have diverticulitis, and then they end up with a stricture and will come to the emergency room with a blockage or not being able to pass stool for several days,” Kavalukas says. “We come to find out that the area has narrowed and they had diverticulitis, and it just didn’t bother them as much as you thought it would.”
Treatment Options for Diverticulitis
For many years, physicians advised persons with diverticula to avoid eating nuts, seeds, and popcorn. Doctors thought these foods could lodge in the outpouches and cause inflammation. But now Kavalukas says research has proven eating them does not provoke diverticulitis. Any dietary recommendations she offers come from large population studies that have shown an association between eating a lot of red meat and having diverticular disease. The same associations occur with lack of exercise, having a high body mass index (BMI), and smoking.
“If a person comes into my office and asks, ‘Do I have to change my diet because I have diverticulitis?’ my answer is 100 percent no,” Kavalukas says.
The decision to prescribe antibiotics to treat patients with diverticulitis is made on a case-by-case basis, Kavalukas says. She cites two large studies that show giving antibiotics for mild diverticulitis do not result in any improved outcomes in the long term. On the other hand, she still prescribes them for patients who have severe diverticulitis or who appear on their way to having it. She says she wants to ward off any large abscesses forming due to the initial inflammation and infection.
“I think it’s kind of a happy medium between how bad your symptoms are, what your white (blood cell) count is, and let’s go from there,” she says.
Taking over-the-counter probiotics – dietary supplements that contain microorganisms that improve digestion – has become popular in recent years to promote overall gastrointestinal health. Kavalukas says she is generally in favor of probiotics, especially the ones containing the Lactobacillus bacteria.
Kavalukas treats patients with diverticulitis conservatively at first and will have a discussion with them about the risks of surgery. She says some patients are wary of getting diverticulitis because they fear they’ll have a fistula develop that opens to the skin and then have to permanently wear a stoma (a bag to collect expelling fluid from the orifice). However, studies have found that the probability of having a fistula form decreases after each episode of diverticulitis due to the formation of scar tissue in the colon.
“If you are somebody who has been to the emergency room three or four times in the past year, or you’ve been hospitalized twice in the past year, or you’re missing days off from work and are like, ‘I can’t stand this happening again,’ it’s probably reasonable to do an operation,” Kavalukas says.
Surgery for diverticular disease is either done laparoscopically or, increasingly, by using robotics. In laparoscopic surgery, Kavalukas says that port sites are created with small incisions to insert straight tools that the surgeon then uses to resect (cut out) the affected part of the colon and reattach the remaining sections.
“With robotic surgery, a robot is not doing your surgery. We usually sit at a console and operate the robot. You still use the same port sites, but you dock robot arms to them and then the surgeon sits down at the console and controls them,” she explains. “The key element of that is the ends of those instruments are wristed and they can do every single thing that my fingers do.”
Kavalukas prefers robotic surgery for complex cases of diverticulitis, such as when the colon becomes attached to another organ. She says it allows the surgeon to do things through a small incision that would otherwise require opening up the patient. The goal for the procedure is to remove the segment of a patient’s colon that is inflamed and infected.
“I cannot do anything that can prevent the diverticula from coming back, because as we’ve discussed we don’t actually know what causes them,” she adds. “A lot of people will have diverticula throughout their entire colon, and I’m not going to take the entire colon out, so you’re really out to (remove) the segment that has the most inflammation or that’s attached to the bladder or somewhere that it’s not supposed to be, and then hook things back together so they won’t know the difference when they wake up.”
If the surgery is successful, Kavalukas says the patient won’t have to make any significant changes to their daily routines, and gastrointestinal function should resume as normal, minus the pain of diverticular disease. She does recommend patients follow a high-fiber diet, using supplements if necessary, as well as exercise more and use the surgery as an opportunity to quit smoking, if they did so previously.
“I think that for almost every condition I treat as a colorectal surgeon, fiber is my answer,” Kavalukas says. “The way fiber works is that it’s a stool-bulking agent. We like to say that it cleans up the stool, so that when you pass the stool through your colon, you’re less likely to leave little pieces behind that can get trapped in the diverticula and get infected.”