Symptoms

The signs and symptoms of  diverticulitis include:

• Sudden apparition of very intense abdominal pain, in the bottom left part of the abdomen (side and left iliac fossa).  Less frequently, the pain can be slight at the beginning, and get worse afterwards.
• Fever
• Nausea and vomiting
• Bloating.
• Gastrointestinal transit disorders: Constipation, Diarrhoea.

Causes

Diverticula generally develop at the anatomic weak spots of your colon.

The mechanism which underlies the onset of complications is not clearly established.

One of the theories stipulates that the obstruction of the neck of the diverticulum, increases the pressure and reduces the supply of blood in the area, which leads to inflammation and secondary infections.  

In the past, doctors thought that nuts, grains and pop-corn played a role in the apparition of a diverticulum.

Age: You have a greater risk of suffering from a diverticulum if you are older than 40:  the diminution in strength and elasticity of the intestinal wall, linked to age, may contribute to a diverticulum.

Nutrition poor in fibre: Diverticula are rare in countries where people follow a regimen rich in fibre, which contributes to maintaining soft bowel movements. But this condition is rife in industrialised countries where the average diet is high in refined carbohydrates and low in fibre.

Obesity and Lack of Exercise: Excess weight considerably increases the risk of developing diverticulitis.

Complications: Peritonitis, Abscess, Enteric fistula, Stenosis of the sigmoid colon, and Rectorrhagia.

Acute cases of diverticulitis require hospitalisation and sometimes urgent surgical treatment.

Peritonitis

• Can occur if infected or inflamed diverticula burst, discharging their intestinal content in your abdominal cavity. This can subsequently cause inflammation of the mucus of the abdominal cavity (the peritoneum).
• Peritonitis requires immediate medical care, and surgery treatment is needed urgently.

Abscess

• These occur around a perforated diverticulum. An abscess can be aspirated by introducing a syringe needle through the skin, guided by echography or a CT scanner.  A drain is then fitted to evacuate the contents of the abscess. The catheter may have to stay in place for the duration of your stay in hospital. You will also be given a treatment of antibiotics. When you have recovered, you will need bowel resection surgical treatment (partial colectomy).

Enteric fistula

• Is an abnormal connection between your intestine (sigmoid) and different organs (the bladder, the vagina, the abdominal wall).

Stenosis of the sigmoid colon

• Can be caused by gastrointestinal transit disorders, or an intestinal occlusion. Even though it seems there is no direct connection between diverticulitis and colon cancer, it may make cancers more difficult to diagnose.
• What may look like  diverticulitis may be colon cancer. So, sometime after your diverticulitis, we recommend you undergo a colonoscopy. A colonoscopy is a test to check inside your bowels, colon and rectum. A long, thin, flexible tube with a small video camera inside it is passed into your bottom (endoscopy).

Rectorrhagia

• Is rectal bleeding not associated with defecation . The bleeding is arterial, from the arteries around the necks of diverticula. The data is globally favourable as 70% to 80% is spontaneous haemorrhaging. However, sometimes such haemorrhaging is badly tolerated.
• Angiography may allow the selective embolisation or the diverticulum arteries responsible for the bleeding, and resolve the problem.
• It is rare that urgent surgical treatment is required  (segmental colectomy or blind subtotal colectomy).

Deferred surgery.

Left hemicolectomy or prophylactic sigmoidectomy after diverticulitis.

The delay between surgery and the last case of diverticulitis must be at least 3 months.

The potential benefits and risks of this surgery must be discussed on a case by case basis.

Indications of a prophylactic sigmoidectomy.

After two cases of complicated sigmoiditis with scan view signs of the gravity of an acute case, in a patient under 50.

A left hemicolectomy is the name of the procedure of surgical resection of the lesions localised on the left half of  the descending sigmoid transverse colon.  A sigmoidectomy is the resection of the sigmoid colon.

Depending on the degree of inflammation, the surgery will be traditional or mini-invasive (laparoscopy (coelioscopy) – keyhole surgery).

In conventional surgery, a large incision is required, whereas the left hemicolectomy by keyhole surgery (laparoscopy) is a mini-invasive surgical operation.  It is carried out through three or four small incisions.

The operating time for a left hemicolectomy varies between 1h and 3h30, depending on the weight of the patient and the difficulties encountered.

Active mobilisation and early food replenishment are necessary for recuperation.

In general, surgery for a  partial colectomy by keyhole surgery takes a little longer.  However, convalescence is a lot quicker.

Technique of a sigmoidectomy by coelioscopy with 3 trocars:

• Coloepiploic detachment.
• Ligation of the inferior mesenteric vein.
• Detachment of the root of the transverse mesocolon and the left colic angle.
• Opening the left Toldt’s fascia allowing the mobilisation of the left colon and the iliac colon. 
• Identify the left ureter from the exterior.
• Section the trunk of the Sigmoid arteries (preserving the upper left colic artery) using vascular clips under the promontory removing the recto-Sigmoid hinge.
• Exteriorisation of the colon by a 4cm incision in the right iliac fossa or suprapubic, colic section. Calibrate and insert the tip of the mechanical circular clamp.
• Reintegrate everything, close the incision, recreate the pneumoperitoneum.
• High latero-terminal mechanical colo-rectal anastomosis, the successful closing of which is verified by injecting betadine serum + an air test.

Diagnosis of Diverticulitis

Diverticulitis is generally diagnosed when an acute attack happens.

However, abdominal pain could be a symptom of a number of disorders.

Your GP/Family doctor must eliminate other causes of abdominal pain (Appendicitis, Irritable colon syndrome, Inflammatory bowel disease, Colon cancer … )

The surgeon will confirm the diagnosis of diverticulitis.

Clinical examination by the surgeon

Blood sample: To check the level of white blood cells, looking for signs of infection.

CT scanner: High performance imaging examination (better than an echography) for a complete view of your internal organs.