Classification

First, a distinction is made between symptomless diverticulosis and symptomatic diverticulitis. Diverticulosis is a wall protrusion of the intestine and is not inflamed. It is very common and affects about 60% of all people > 70 years of age in industrialized countries.

Diverticulitis, also called symptomatic diverticulitis, is the inflammation of this wall protrusion and is further divided into stages depending on the severity of the inflammation. Furthermore, so-called pseudodiverticula can be distinguished from true diverticula. The pseudodiverticula (=false diverticula) are localized in the sigmoid colon (lower section of the colon) in 2/3 of the cases.

They are caused by vascular gaps in the muscular intestinal wall and merely denote a protrusion of the intestinal mucosa. Genuine diverticula, on the other hand, are much rarer and are often found in the coecum (transition from small intestine to large intestine). This is a protrusion of all layers of the intestinal wall.

Complications

Such an inflamed diverticulum can break open and the inflammation can spread to the abdominal cavity. Followed by peritonitis, this is probably the most severe complication and must be operated on immediately. It can also occur.

The formation of fistulas is also possible. Fistulas are connections between two intestinal loops. However, these fistulas can also develop between the intestine and other organs.

Fistulas between the intestine and the bladder are also conceivable and sometimes occur. This is particularly common in Crohn’s disease.

Bleeding
Blockages or even
Blood Poisoning

In the case of a first, uncomplicated relapse of diverticulitis, the conservative, non-surgical approach is taken first.

This usually consists of an in-patient stay, food leave, venous administration of fluids (infusion) and antibiotics. In contrast to diverticulitis, a low-fiber diet should be followed until complete healing.Spasmolytics, e.g. Buscopan®, can be taken for cramp-like abdominal pain. Metamizole, pethidine or buprenorphine can also be used for pain therapy.

Morphine itself should not be used in diverticulitis due to the increase in pressure in the bowel. This therapy is already sufficient for 65% of diverticulitis. If there is no improvement after 24-48 hours, surgical therapy may be considered.

If an inflammatory relapse (diverticulitis) occurs for the second time, a planned operation after the inflammation has healed should be considered. The surgery should reduce the risk of complications in case of further relapses. Especially in young patients (under 40) and immunocompromised risk patients, there is a tendency towards an early intervention due to the high probability of recurrence.

In other patients, a third or fourth relapse may also pass before the decision to undergo surgery is made. Surgically, the highly inflammatory bowel segments can be removed and the healthy parts rejoined: End-to-end connection (anastomosis). Depending on the extent and location of the defect, different surgical techniques are used.

For example, the keyhole technique (laparoscopy) is usually used for non-complicated diverticulitis. Depending on the circumstances and the patient, open abdominal surgery with a larger skin incision can also be advantageous. In case of perforation (bursting of a diverticulum, intestinal rupture), constrictions (stenoses), intestinal obstructions (ileus), abscesses (encapsulated accumulation of pus), or fistula formation (tubular connection) with and without peritonitis (inflammation of the peritoneum), immediate or prompt surgical therapy is recommended.

If the diverticula are perforated, an artificial bowel outlet (colostomy) is often attached (Hartmann operation). This means that the upper part of the intestine is connected to the abdominal wall. The defecation is then passed through an artificial hole in the abdominal wall into a bag attached externally to the abdomen.

The lower section of the bowel, which is located further towards the anus, is closed first. Once the inflammation in the abdominal cavity has subsided, both ends of the intestine can be reconnected after 12-16 weeks at the earliest. In particularly severe cases of contamination of the abdominal cavity, a programmed abdominal lavage may be necessary.

If a patient is not in a sufficiently good general condition, an ultrasound– or CT-guided outflow (drainage) of the inflammatory secretion is possible in case of an abscess or perforation. After 7-10 days, when the patient is in better condition, the affected colon section can be removed. If the diverticulitis is the trigger of sepsis (blood poisoning), the stabilization of the patient is the main focus.

Surgical treatment of the focus of inflammation follows as soon as possible. In case of bleeding, the extent of the bleeding must first be determined. Depending on the necessity, a wait-and-see procedure can be performed, an emergency colonoscopy with haemostatic measures up to open emergency surgery. An appropriate diet should be followed in all phases of the disease.