Diverticulosis is managed by increasing the fiber content of the diet, while removing irritating substances such as nuts, corn, popcorn, and similar foodstuffs, including the small seeds found in berries, tomatoes, cucumbers, and figs. Increased fiber is achieved by taking bran, root vegetables, and certain greens. Commercially-available bulk forming agents such as psyllium are helpful. Sometimes antispasmodic medication gives relief. Regular meals and adequate fluids are important.
Having said all this, there is no "silver bullet" (guaranteed cure) for symptoms associated with diverticulosis. Altering the muscular action of the colon is not an easy job and intermittent bouts of abdominal cramping or change in bowel habit may remain more or less features of that individual. Sometimes symptoms will just go away for no particular reason, and sometimes they will return. Surgery is almost never indicated in the absence of significant bouts of diverticulitis.
Treatment of diverticulitis
The type of treatment depends on how ill the patient is.
Treatment of the typical mild case of diverticulitis
Fortunately, the vast majority of patients with diverticulitis have a mild event and can be treated "conservatively" (without surgery). In these common, mild cases, the patient will have a change in bowel habit, some left lower quadrant discomfort and tenderness, perhaps a mildly elevated temperature and a slightly increased white blood cell count. Treatment should include bowel rest by means of a fluid diet for a day or so followed by a low fiber diet for a couple of weeks, generalized rest, and antibiotics active against bowel organisms. Oral pain medicine may be used and sometimes oral bowel-antispasmodic agents are prescribed. A high fiber diet during an attack of diverticulitis should be avoided. The patient can expect significant improvement in symptoms within 3 to 4 days. If there is no such improvement, or matters worsen, or attacks become frequent, surgery may be necessary.
Treatment of diverticulitis that recurs frequently
If the disease recurs often, the patient will have a choice between putting
up with the recurrent trouble or having an operation to remove the
offending segment of bowel. The choice comes down to personal preference
of the patient, experience of the physician with similar cases,
the speed at which the recurrences respond to treatment, and the
certainty with which more serious conditions can be ruled out. Sometimes
in a segment of bowel that undergoes repeated inflammation, the
inside becomes so contracted and irregular that a colonoscope can
no longer be passed into the area to rule out the possibility that
the trouble may be something new, like a colon cancer. In such cases
it is best to remove the segment in order to provide peace of mind
that nothing sinister can develop in an area that cannot be examined
(diverticulitis does not cause colon cancer but their symptoms may
be similar and they do appear in similar age groups).
Another reason to intervene with surgery is the geographic location of the
individual. If the patient is planning to travel to the third world
or a frontier where surgery or modern treatment is not available,
it may be best to deal with the issue definitively ahead of time,
if the patient gets frequent attacks.
If surgery is performed in a patient with recurrent attacks, it should not
be done during an attack. Instead, surgery should be performed when
the patient is feeling well in order to ensure that the ends of
the bowel can be reconnected immediately and that no colostomy will
Treatment of severe cases of diverticulitis
Severe cases will usually involve some degree of perforation. The patient
will be ill, with significant irritation of the abdominal cavity
(peritonitis). Even in these cases, it is best to treat initially
without surgery since the patient will often benefit from a course
of hospitalization and careful monitoring, complete bowel rest,
intravenous fluids, and intravenous antibiotics. In most cases,
the patient will improve over 12 to 24 hours and as the condition
settles, additional diagnostic studies can be carried out and surgery
considered. If the patient is recovering nicely, it may be best
to postpone any plan for surgery until complete recovery so as to
permit thorough preparation of both the bowel and the patient for
In cases in which initial treatment does not yield rapid results, or in patients who arrive at hospital "in extremis" (very ill with evidence of free or widespread perforation, or severe left lower quadrant peritonitis), urgent surgery is required. Surgery should still be preceded by rapid administration of intravenous fluids and intravenous antibiotics, and, if time, marking by a stomatherapist of the abdominal wall for the optimum placement of a colostomy site.
The operation for severe cases will be performed under general anesthetic, through an incision that generally goes down the middle of the abdomen. Although some surgeons are experimenting with laparoscopic surgery (surgery using small instruments through small incisions), the majority would not use it in patients this ill.
The surgeon will open the abdomen and assess the situation. The goal of the
operation is to wash out the abdominal cavity to remove offending
substances that may have leaked out of the bowel, and to remove
the abnormal segment of bowel in order to ensure there is no further
leakage. Whether the surgeon can reconstitute the bowel (put the
ends together - called an "anastomosis") after removing the diseased
segment will depend on a number of things including: the amount
of infection or inflammation encountered in the abdominal cavity,
the immediate condition of the patient, other associated illnesses
the patient may have at the time, and the surgeon's personal preference
and experience. In general, if there is a lot of leakage and inflammation,
it is best not to put the ends of the bowel together since failure
of healing of an anastomosis in an inflamed abdomen occurs more
frequently than from an anastomosis in an abdomen that has had a
chance to recover.
If the surgeon decides not to put the bowel ends together, the upper end
of the bowel will be brought out to the surface of the abdomen so
that its contents may drain out into a bag. This is called a colostomy.
The bottom end of the bowel may be brought out in the lower end
of the incision (this is called a "mucus fistula"), or stapled off
entirely and left within the pelvis. The bottom end is not an active
(stool-carrying) end so it is not as important as the upper end
through which the stool must pass. If the bottom end of bowel is
left within the pelvis, the operation is called a Hartmann Procedure,
named after a famous French surgeon. After the patient has fully
recovered, the surgeon will reoperate on the patient and put the
2 ends of bowel together 6 to 12 weeks after the initial emergency
surgery, thus completing the 2-stage surgical treatment for repair
of a perforated diverticulitis.