Diverticulitis Treatment in Dallas, TX

What Is Diverticular Disease?

Diverticular disease is an umbrella term that encompasses two related conditions: diverticulosis and diverticulitis. Understanding the distinction between these two conditions is important for patients and is one of the most common topics discussed in gastroenterology.

Diverticulosis refers to the presence of small, bulging pouches (diverticula) that form in the wall of the colon, most commonly in the sigmoid colon (the lower left portion of the large intestine). Diverticulosis is extremely common, particularly in Western countries, and its prevalence increases with age. By age 60, more than 50 percent of Americans have diverticulosis, and by age 80, the prevalence exceeds 70 percent. In the vast majority of cases, diverticulosis causes no symptoms whatsoever and is discovered incidentally during a colonoscopy or imaging study performed for another reason.

Diverticulitis occurs when one or more diverticula become inflamed or infected, leading to abdominal pain (typically in the left lower abdomen), fever, and changes in bowel habits. Approximately 4 to 5 percent of people with diverticulosis will develop diverticulitis at some point in their lives. While most episodes of diverticulitis are uncomplicated and resolve with conservative treatment, some cases can lead to serious complications that require hospitalization or surgery.

At Texas Gut Health in Sachse, TX, Dr. Jaison John provides comprehensive management of diverticular disease, from acute diverticulitis treatment to long-term prevention strategies. Dr. John completed his gastroenterology fellowship at UT Medical Branch, where he served as Chief Fellow, and his internal medicine residency at UT Austin Dell Medical School, where he served as Chief Resident. He holds dual board certifications from the American Board of Internal Medicine in both internal medicine and gastroenterology.

Causes and Risk Factors

The development of diverticula (diverticulosis) is believed to result from a combination of increased pressure within the colon, age-related changes in the colon wall, and dietary and lifestyle factors. The following risk factors have been identified:

• Age — The most significant risk factor. The prevalence of diverticulosis increases dramatically with age, likely due to age-related weakening of the colon wall and changes in collagen structure.
• Low-fiber diet — A diet low in fiber is associated with increased intracolonic pressure and a higher prevalence of diverticulosis. Fiber adds bulk to stool and promotes regular bowel movements, which helps reduce pressure on the colon wall. The observation that diverticular disease is rare in parts of Africa and Asia where high-fiber diets are common supports this association.
• Obesity — Being overweight or obese increases the risk of both diverticulosis and diverticulitis, as well as the risk of complications such as perforation and the need for surgery.
• Physical inactivity — A sedentary lifestyle is associated with increased risk of diverticular disease. Regular physical activity appears to be protective.
• Smoking — Smoking increases the risk of developing diverticulitis and its complications.
• Medications — Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, and opioids has been associated with an increased risk of diverticulitis and diverticular bleeding.
• Genetics — Twin studies suggest that genetic factors may account for approximately 40 to 50 percent of the susceptibility to diverticular disease.

The exact mechanism by which diverticulitis develops is not fully understood. Current theory suggests that micro-perforations in diverticula, combined with alterations in the colonic microbiome and localized immune response, trigger the inflammatory process.

Symptoms of Diverticulitis

The symptoms of diverticulitis can range from mild to severe depending on the extent of inflammation and whether complications are present.

Uncomplicated Diverticulitis

• Abdominal pain — The hallmark symptom, most commonly located in the left lower abdomen (left lower quadrant). The pain is often described as constant, cramping, or aching and may develop gradually or come on suddenly. In patients of Asian descent, pain may occur on the right side due to the higher prevalence of right-sided diverticula.
• Fever — Low-grade fever (100 to 101 degrees Fahrenheit) is common with uncomplicated diverticulitis.
• Nausea and vomiting — May accompany the abdominal pain, particularly if ileus (temporary slowing of bowel function) develops.
• Changes in bowel habits — Constipation is more common, though some patients experience diarrhea.
• Abdominal tenderness — Localized tenderness, typically in the left lower abdomen, on physical examination.
• Urinary symptoms — Frequency, urgency, or discomfort with urination may occur when inflamed diverticula are adjacent to the bladder.

Complicated Diverticulitis

Approximately 12 to 15 percent of diverticulitis episodes involve complications, which may include:

• Abscess — A walled-off collection of pus that forms adjacent to the inflamed segment of colon. Small abscesses may resolve with antibiotics; larger abscesses may require CT-guided percutaneous drainage.
• Perforation — A rupture of the colon wall that can release intestinal contents into the abdominal cavity, causing peritonitis (widespread inflammation of the abdominal lining). This is a surgical emergency.
• Fistula — An abnormal connection between the colon and an adjacent organ, most commonly the bladder (colovesical fistula), vagina (colovaginal fistula), or skin. Colovesical fistula may cause recurrent urinary tract infections, passage of gas during urination (pneumaturia), or fecal material in the urine.
• Obstruction — Repeated episodes of inflammation and scarring can narrow the colon, potentially causing partial or complete bowel obstruction.
• Diverticular bleeding — While diverticular bleeding is technically a separate entity from diverticulitis (inflammation), diverticula can erode into a blood vessel and cause significant, painless rectal bleeding. Diverticular bleeding is one of the most common causes of lower gastrointestinal bleeding in older adults.

Diagnosis

Accurate diagnosis of diverticulitis is essential for guiding appropriate treatment and ruling out other conditions that can present similarly, including colorectal cancer, inflammatory bowel disease, and ovarian pathology in women.

CT Scan

CT scan of the abdomen and pelvis with intravenous contrast is the gold standard for diagnosing acute diverticulitis. CT provides detailed imaging that can:

• Confirm the diagnosis by showing pericolonic fat stranding, colon wall thickening, and inflamed diverticula
• Identify complications such as abscess, free perforation, fistula, and obstruction
• Classify severity to guide treatment decisions
• Help differentiate diverticulitis from other causes of abdominal pain

Laboratory Tests

Blood tests during acute diverticulitis typically show elevated white blood cell count (leukocytosis) and elevated C-reactive protein (CRP), markers of inflammation and infection. Urinalysis may be performed to evaluate for urinary tract involvement.

Follow-Up Colonoscopy

Colonoscopy is not performed during an acute episode of diverticulitis due to the risk of perforation. However, the American Gastroenterological Association (AGA) and the ACG recommend a follow-up colonoscopy approximately 6 to 8 weeks after recovery from an acute episode, particularly after a first episode or if a recent colonoscopy has not been performed. The primary purpose is to rule out colorectal cancer, which can mimic diverticulitis on CT imaging. Studies have demonstrated that approximately 1 to 2 percent of patients diagnosed with acute diverticulitis on CT are found to have an underlying colorectal malignancy on subsequent colonoscopy.

Treatment

Treatment of diverticulitis depends on the severity of the episode and whether complications are present.

Uncomplicated Diverticulitis

Most episodes of uncomplicated diverticulitis can be managed in the outpatient setting. Treatment approaches include:

• Dietary modification — During an acute flare, a clear liquid diet for 2 to 3 days allows the colon to rest. As symptoms improve, the diet is gradually advanced to low-residue foods and eventually back to a normal diet.
• Antibiotics — Traditionally, oral antibiotics (typically a combination of ciprofloxacin and metronidazole, or amoxicillin-clavulanate) have been the standard of care. However, recent evidence from randomized controlled trials, including the landmark AVOD and DIABOLO studies, has shown that mild, uncomplicated diverticulitis in immunocompetent patients may resolve without antibiotics. The AGA's 2015 guideline suggests that antibiotics should be used selectively rather than routinely for uncomplicated diverticulitis. Dr. John evaluates each case individually to determine whether antibiotics are indicated.
• Pain management — Acetaminophen (Tylenol) is the preferred analgesic. NSAIDs should be avoided as they may worsen diverticulitis and increase the risk of perforation. Opioids should be used with caution as they slow colonic motility.
• Rest and hydration — Adequate rest and fluid intake support recovery.

Complicated Diverticulitis

Patients with complicated diverticulitis typically require hospitalization for:

• Intravenous antibiotics — Broad-spectrum IV antibiotics to treat the infection.
• CT-guided percutaneous drainage — Abscesses larger than 3 to 4 centimeters are generally drained using a catheter placed under CT guidance, which can serve as a bridge to either resolution or elective surgery.
• Bowel rest — Nothing by mouth (NPO) with IV fluid support.
• Surgical consultation — Surgery is indicated for free perforation with peritonitis, failed percutaneous drainage, fistula, obstruction, or recurrent episodes that significantly impair quality of life.

When Surgery Is Needed

The decision to recommend surgery for diverticulitis has evolved significantly. Current guidelines emphasize individualized decision-making rather than a rigid algorithm based on the number of episodes. Surgery (typically a sigmoid colectomy) is considered in the following situations:

• Emergency surgery for free perforation with generalized peritonitis (Hinchey III or IV)
• Failure of conservative management for a complicated episode
• Fistula formation (colovesical, colovaginal, or colocutaneous)
• Colonic obstruction due to stricture from recurrent inflammation
• Recurrent episodes that significantly impact the patient's quality of life, after careful discussion of risks and benefits
• Inability to exclude malignancy

The AGA recommends against routine elective surgery solely based on the number of uncomplicated episodes, as the risk of recurrence after any given episode is lower than previously believed.

Prevention

While diverticulosis cannot always be prevented, several evidence-based strategies can reduce the risk of developing diverticulitis and its recurrence:

• High-fiber diet — The AGA recommends a fiber-rich diet or fiber supplementation for patients with a history of acute diverticulitis. The recommended daily fiber intake is 25 to 35 grams per day. Good sources include fruits, vegetables, whole grains, legumes, and fiber supplements such as psyllium husk. Fiber should be increased gradually to avoid bloating and gas.
• Regular physical activity — Vigorous physical activity has been shown to reduce the risk of diverticulitis by approximately 25 percent. The recommended minimum is 150 minutes of moderate-intensity exercise per week.
• Weight management — Maintaining a healthy body weight reduces the risk of diverticulitis and its complications.
• Smoking cessation — Quitting smoking reduces the risk of diverticulitis and improves overall health outcomes.
• Limiting NSAIDs and aspirin — Reducing the use of NSAIDs and aspirin, when medically appropriate, can lower the risk of diverticulitis and diverticular bleeding.
• Seeds, nuts, and popcorn are safe — A landmark study published in the Journal of the American Medical Association (JAMA) in 2008 involving over 47,000 men found no increased risk of diverticulitis or diverticular complications associated with nut, corn, or popcorn consumption. The AGA has explicitly stated that there is no evidence to support restricting these foods.

Frequently Asked Questions