Diverticulitis is a common digestive disease characterized by inflamed pouches (diverticula) in the colon wall. It often develops when diverticula become infected or inflamed. Symptoms of diverticulitis include abdominal pain, fever, nausea, vomiting, chills, cramping, and constipation. Mild diverticulitis can be treated with rest, changes in diet, and antibiotics. However, some people experience recurrent episodes of diverticulitis that may require surgery. This article examines how many episodes of diverticulitis typically occur before a surgical intervention is recommended.
What is Diverticulitis?
Diverticula are small pouches that can form in the wall of the colon. Although most people with diverticula don’t have any symptoms, inflammation or infection of the pouches leads to diverticulitis. Diverticulitis occurs when diverticula become blocked and bacteria grows inside them, causing infection and inflammation. This usually happens when stool gets trapped in the pouches.
Diverticulitis can range in severity from mild to life-threatening. Symptoms include:
- Abdominal pain, usually in the lower left quadrant
- Fever
- Nausea and vomiting
- Bloating
- Constipation or diarrhea
- Urinary symptoms
Risk factors for developing diverticulitis include:
- Aging
- Lack of fiber in the diet
- Obesity
- Smoking
- Lack of exercise
- Regular use of anti-inflammatory medications
Diverticulitis is diagnosed based on symptoms, medical history, physical exam, and imaging tests like CT scans or ultrasounds. It’s important to differentiate it from other causes of abdominal pain. Treatment depends on the severity but may include antibiotics, intravenous fluids, bowel rest, and rarely, surgery.
Stages of Diverticulitis
Diverticulitis can be divided into several stages:
Uncomplicated Diverticulitis
This is a mild infection of one or more diverticula. Symptoms are usually mild. It typically responds well to oral antibiotics and bowel rest.
Complicated Diverticulitis
This is a more severe infection causing abscess, phlegmon, fistula, obstruction, or perforation. Hospitalization, IV antibiotics, and possibly surgery are needed.
Recurrent Attacks
About 20% of people have repeated attacks of diverticulitis after the initial episode resolves. The risk of recurrence increases with each episode.
Chronic Diverticulitis
Repeated bouts of inflammation cause chronic irritation, pain, and bowel changes. Elective surgery may be recommended.
When is Surgery Recommended?
Many doctors follow the “three strikes” rule for diverticulitis surgery:
- First episode of uncomplicated diverticulitis – Treat with antibiotics
- Second episode – Treat again with antibiotics
- Third episode – Elective surgery may be recommended after the attack resolves
However, this approach remains controversial. Some experts say the number of episodes alone should not dictate surgery. The decision depends on other factors like:
– Age
– Severity of attacks
– Time between episodes
– Persistent symptoms
Younger patients under age 50 may be offered surgery earlier, after even one severe attack. Older patients are more likely to be managed medically without surgery.
Emergent Surgery
Emergency surgery is required in about 25% of diverticulitis cases, usually for complications like:
- Perforation
- Peritonitis
- Abscess
- Fistula
- Sepsis
- Bowel obstruction
- Uncontrolled bleeding
So while multiple episodes often lead to elective surgery, life-threatening complications mean urgent surgery is needed regardless of past episodes.
Types of Surgeries for Diverticulitis
Surgery for diverticulitis aims to remove the affected segment of colon and rejoin the healthy ends. Common operations include:
Sigmoid Colectomy
Removing the left side of the colon (sigmoid colon) where diverticula most often form. This is the most common surgery for diverticulitis.
Left Colectomy or Extended Left Colectomy
Removing part or all of the left colon, along with the upper rectum. Done for more extensive disease.
Hartmann Procedure
Removing the sigmoid colon and sealing off the rectal stump. Used in emergencies with significant infection or contamination.
Bowel Resection
Removing the segment of diseased bowel and reconnecting healthy ends. This preserves intestinal continuity.
Colostomy
Creating an opening from the colon to the abdominal wall. The end of the colon is brought through the opening, allowing stool to exit into a bag. This is typically temporary.
Non-Surgical Options
For those wishing to avoid surgery, options include:
– **Lifestyle changes** – Eating high fiber, exercising, maintaining healthy weight, and quitting smoking may prevent progression of diverticular disease.
– **Medications** – Antibiotics or antispasmodics can treat symptoms. Avoiding NSAIDs reduces inflammation.
– **Probiotics** – May help regulate gut bacteria and prevent recurrent episodes. Evidence is limited.
– **Alternative treatments** – Some patients use supplements, acupuncture, or other modalities. More research is needed on their effectiveness.
However, for advanced or complicated diverticulitis, surgery offers the best long-term results. Non-surgical options work best for maintaining remission after the colon has healed.
Conclusion
The conventional recommendation has been elective surgery after two episodes of diverticulitis. But treatment must be individualized, weighing factors like age, disease severity, time between attacks, ongoing symptoms, and quality of life. Surgery is absolutely indicated for emergencies like perforation or peritonitis.
Younger patients may undergo surgery sooner, while elderly patients often avoid surgery if the diverticulitis can be well-controlled medically. Non-surgical options focus on preventing future episodes through lifestyle changes and medications. Close follow-up is essential to monitor for disease progression and determine optimal timing for surgery, if needed. With the right treatment approach, most patients with diverticulitis recover well and maintain remission.