Diverticular Disease

Diverticular disease is a common condition that affects the colon, where small pouches called diverticula form in the intestinal wall. While many people with diverticulosis (the presence of diverticula) remain symptom-free, some may develop diverticulitis, an inflammatory condition that can cause pain, infection, and complications. While mild cases can be managed with lifestyle modifications and medication, severe or recurrent diverticulitis may require surgical intervention.

The colon, also known as the large intestine, is a crucial part of the digestive system, responsible for proper digestion and waste elimination by:

• Absorbing water and electrolytes from undigested food.
• Forming and storing stool before elimination.
• Maintaining gut microbiota balance, which supports digestion and immunity.

When diverticula form, they can alter the structure and the normal function of the colon:

• Increased pressure and weakness in the colon wall.
• Inflammation leading to swelling and discomfort.
• Scar tissue formation, potentially causing strictures (narrowing of the colon).
• Risk of infection and perforation, leading to serious complications.

Over time, recurrent inflammation can lead to chronic digestive issues and structural changes, requiring medical or surgical intervention.

Why Cuba

Elective surgical treatment for Diverticular Disease in Cuba is performed by a multidisciplinary team of healthcare professionals, including general surgeons and gastroenterologists. The primary goal is to prevent recurrent episodes of diverticulitis, alleviate chronic symptoms, and reduce the risk of serious complications by removing the affected portion of the colon while preserving normal digestive function. Surgery is recommended based on the frequency and severity of attacks, the presence of complications such as abscesses or strictures, the impact of the condition on daily life and quality of life, and the patient’s overall health status.

IMPORTANT TO NOT: IF THE BELOW COMPLICATIONS ARISE, URGENT MEDICAL CARE IS REQUIRED.

Immediate surgery is necessary when:

• Bowel perforation occurs, causing life-threatening infection (peritonitis).
• Severe abscess that does not respond to antibiotics or drainage.
• Complete bowel obstruction due to inflammation or scarring.
• Uncontrolled rectal bleeding requiring surgical intervention.
• Fistula formation, leading to chronic infections.

Types and Classification of Diverticular Disease

Diverticular disease is classified based on the presence of diverticula, symptoms, and complications. It is broadly categorized into three main types, each with varying degrees of severity.

• Diverticulosis (Presence of Diverticula)
  • The presence of small pouches (diverticula) in the colon, typically in the sigmoid colon.
  • Often asymptomatic and discovered incidentally during a colonoscopy or imaging tests.
  • Key Characteristics:
    • No symptoms in most cases.
    • May cause mild bloating or changes in bowel habits.
    • Can progress to symptomatic diverticular disease or diverticulitis in some individuals.

• Symptomatic Uncomplicated Diverticular Disease (SUDD)
  • When diverticula cause chronic symptoms without active infection or severe complications.
  • Key Characteristics:
    • Mild abdominal pain, usually in the lower left side.
    • Bloating, constipation, or diarrhea.
    • Symptoms persist but without inflammation or infection.

Diverticulitis (Inflammation or Infection of Diverticula)

• When diverticula become inflamed or infected, it leads to moderate to severe abdominal symptoms.

• Types of Diverticulitis:
  • Uncomplicated Diverticulitis
    • Localized inflammation without complications.
    • Managed with antibiotics, diet, and supportive care.
    • Symptoms usually resolve within a few days.

• Complicated Diverticulitis
  • Abscess formation (pocket of pus in the colon).
  • Bowel perforation, leading to peritonitis (infection in the abdominal cavity).
  • Fistula formation (abnormal connection between the colon and other organs).
  • Bowel obstruction (due to inflammation or scar tissue).
  • Severe rectal bleeding if a blood vessel ruptures.

Classification Based on Severity

• Stage I: Small, localized abscess within the colon wall.
• Stage II: Large abscess extending into the abdomen or pelvis.
• Stage III: Perforation causing generalized peritonitis (infection spread in the abdomen).
• Stage IV: Severe infection with widespread fecal peritonitis, requiring emergency surgery.

Causes of Diverticular Disease

Several factors contribute to diverticula formation and inflammation, including:

• Aging: The intestinal wall weakens with age, making it prone to diverticula.
• Low-fiber diet: Leads to constipation and high pressure in the colon.
• Chronic constipation: Straining increases the risk of diverticula.
• Obesity and lack of exercise: Slows digestion and increases colon pressure.
• Smoking and alcohol use: May increase inflammation in the gut.
• Long-term NSAID use: Medications like ibuprofen and aspirin can weaken the intestinal lining.

Symptoms of Diverticular Disease

Diverticular disease symptoms vary based on severity and whether inflammation is present.

Common Symptoms of Diverticulitis include:

• Persistent lower left abdominal pain (most common)
• Bloating and cramping
• Nausea and vomiting
• Constipation or diarrhea
• Fever and chills (if infection is present)

Diagnosis of Diverticular Disease

To diagnose diverticular disease, doctors use clinical evaluation, imaging, and lab tests:

• Physical Exam: Abdominal tenderness in the lower left side.
• Blood Tests: Elevated white blood cells may indicate infection.
• CT Scan: The most accurate test to detect inflamed diverticula and complications.
• Colonoscopy: Performed after recovery to assess the colon.
• Stool Tests: Helps rule out infections.

Elective (Non-Emergency) Surgical Treatment

Diverticular disease affects the colon and can lead to complications such as inflammation, infection, perforation, or obstruction. In cases where non-surgical management fails or the condition recurs frequently, elective surgery is recommended to prevent future complications and improve the patient’s quality of life.

The primary goal of elective surgery is to remove the affected segment of the colon while preserving as much normal bowel function as possible and reducing the risk of future complications.

The choice of surgical procedure depends on the severity of the disease, the patient’s overall health, and the presence of complications.

Primary Bowel Resection (Colectomy with Anastomosis)

This is the most common surgical treatment for diverticular disease, where the diseased section of the colon is removed, and the remaining healthy sections are reconnected. This reconnection is known as anastomosis, allowing for normal bowel function to continue.

• Procedure: The surgeon identifies and removes the damaged portion of the colon.

• Anastomosis: The two remaining ends of the colon are carefully reattached to restore the continuity of the digestive tract.

• Approach: This surgery can be performed using:

• Laparoscopic (Minimally Invasive) Surgery: Small incisions are made, and specialized instruments are used to remove the diseased portion.
• Open Surgery (Laparotomy): A larger incision is made to directly access and remove the affected colon segment.

Hartmann’s Procedure (For Severe Cases) 

Hartmann’s Procedure is primarily used in emergency situations, but in some cases, it can also be performed as an elective surgery when necessary.

Hartmann’s Procedure may be planned in some cases where:

• The patient has a history of complicated diverticulitis and is at high risk for anastomotic leakage if the colon is reconnected immediately.
• Severe fibrosis (scar tissue) or strictures make it difficult to safely reconnect the colon.
• The patient is immunocompromised or has multiple comorbidities that increase the risk of post-surgical complications.
• Previous failed surgeries or non-healing anastomosis require a staged approach.

The procedure is a two-stage surgery designed to manage serious cases effectively.

Stage 1:

• The affected portion of the colon is surgically removed.
• Instead of reconnecting the colon immediately, the surgeon creates a temporary colostomy, where the end of the colon is brought to the abdominal surface, and waste exits the body into a colostomy bag.

Stage 2 (Colostomy Reversal):

• Once the patient has healed and inflammation is resolved, a second surgery is performed.
• The colostomy is reversed, and the remaining healthy colon is reconnected to restore normal bowel function.