When is surgery needed for diverticulitis?

This a somewhat controversial question.  Diverticular disease, or diverticulosis of the colon, is a very common condition in Australia and other western countries.  Diverticulitis is inflammation and infection around the colon due to complications of the diverticular disease.  This is due to perforation of a diverticulum.  Often this perforation, or hole in the bowel, is very small and the body's defenses can cope with it and prevent the development of peritonitis (severe infection within the abdominal cavity).  Most episodes of diverticulitis are mild and can be adequately treated with oral antibiotics or if more severe then admission to hospital, bowel rest and intravenous antibiotics.  

When diverticulitis becomes even more severe it can lead to other complications.  These complications include peritonitis, abscess (a collection of infected pus), fistula (a connection of the bowel to the bladder or vagina leading to discharge of faeces in the urine or through the vagina) or stricture (a narrowing of the bowel preventing the passage of faeces).

Surgery to remove the perforated segment of bowel is almost always required when peritonitis has developed to prevent overwhelming infection that can be fatal.  This operation will often result in a temporary colostomy (commonly known as a bag) but is performed as an emergency life saving procedure.

If an abscess develops from diverticulitis this is most commonly treated by draining the infection using a drain tube placed into the abscess through the skin.  This procedure will usually be guided by an ultrasound or CT scan and is not actually surgery.  Increasingly these abscess may also be drained by a surgeon performing laparoscopic, or keyhole, surgery.

Development of a fistula is uncommon but may occur if diverticulitis persists for a prolonged period.  These fistulas are extremely unlikely to heal without surgery.  In this situation the surgery is typically not an emergency and the diseased segment of bowel is removed and the ends re-joined, often without need for a stoma, or bag.

A stricture develops from chronic inflammation and scarring.  The narrowing become so severe that symptoms of bowel obstruction (pain, bloating and constipation) become so unbearable that surgery is required.  Again this is often not an emergency operation and a stoma is usually not required

People with diverticular disease may experience episodic abdominal pain.  The pain is commonly in the lower abdomen, above the pubic bone and to the left side.  Most of the time, for most people, it is likely that this is simply pain without actual diverticulitis.  The role of surgery in this situation is controversial as it is a major undertaking, it may not relieve all of the symptoms and it may actually create new problems. 

I think Dr Sutherland has summed that up beautifully!  In my own clinical experience, I have found that Diverticular can be managed through Dietary Intervention without surgery for some individuals, so talking to an Accredited Practicing Dietitian may be worthwhile for you.  Dietary intervention normally involves implementing a high fibre diet when the Diverticular is not inflammed and then swapping to a low fibre diet during times of pain/inflammation in order to give your bowels a rest. For a high fibre diet it may be worthwhile investing in a bulking agent (such as Metamucil or Benefibre) in combination with 2 serves of fruit everyday (eg. 1 banana is a serve or 2 mandarins), 5 serves of vegetables (eg. 1/2 cup of cooked vegetables is a serve) and 5 serves of breads/cereals/pasta preferably wholegrain or wholemeal (eg. 1 cup cooked rice, pasta or breakfast cereal is a serve).                                                                                                                                                                                                                                                                                           Samantha Ling                                                                                                                                                             Rostant Nutrition