Exploring Diverticular Disease

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland Clinic Podcast exploring your digestive and surgical health from end to end.

Hi, everybody, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. We are very pleased to have appearance number three on Butts & Guts, Dr. Michael Valente, who's an Associate Professor of Surgery. He's also our program director for our colorectal surgery residency, and Mike also leads our HIPEC program here within the Digestive Disease & Surgery Institute at Cleveland Clinic. Mike, welcome back to Butts & Guts.

Michael Valente: Thanks for having me again.

Scott Steele: Today, we're going to talk a little bit about diverticular disease. But for those new listeners out there who haven't gone back, and should, to listen to your older episodes, just give us a little bit of background about yourself.

Michael Valente: I'm a staff surgeon here in the Department of Colorectal Surgery. Been here for almost nine years now. Born and raised in Cleveland. I do everything from benign diseases from hemorrhoids to rectal cancer, to advanced peritoneal cancer with heated intraperitoneal chemotherapy. I kind of do the whole spectrum of colorectal diseases here.

Scott Steele: We're absolutely glad to have you on board. Mike, we're going to talk today about something that a lot of people have heard of, kind of crosses a lot of different boundaries, and that's diverticular disease. Let's just start way high and talk about terminology.

Michael Valente: Sure.

Scott Steele: How do we kind of differentiate between diverticular disease versus diverticulum versus diverticulosis versus diverticulitis?

Michael Valente: Very common scenario. Diverticular disease is broadly broken up into diverticulosis, which is the presence of, for a lack of better term, pockets or out-pouching of the colon wall. Diverticulosis is very, very common in America. Estimates say 50% of people over the age of 50 will have diverticulosis and others we'll say 80% of people 80 years and over in America will have diverticulosis, and then that may lead to a condition called diverticulitis, which is actual inflammation or an infection of the colon.

Scott Steele: About 25% of people at the high end of diverticulosis may have some bout of diverticulitis, but let's just talk about diverticulitis in general and that's what we're going to focus on here. How does diverticulitis present? Is it everybody gets sick from it, or what is the complications associated with it? How do you break that type of stuff up?

Michael Valente: The vast majority of patients with diverticulitis may exhibit some symptoms of abdominal pain or inability to maybe tolerate food. There's a huge spectrum of symptom presentation with diverticulitis. Some folks have some mild abdominal pain that are treated with an oral antibiotic by their family doctor. Some patients are extremely sick on the other end of the spectrum who need to come to the hospital for intravenous IV antibiotics. Some people, a very low number, require surgery emergently.

Scott Steele: Mike, what type of problems or complications can diverticulitis cause?

Michael Valente: The most common symptom or a complication of diverticulitis is essentially bad pain in your lower belly, which prevents you to eat or sometimes even drink. You have to be on IV fluids and IV antibiotics. Some levels of diverticulitis may have a situation called a perforation where the colon actually opens up and secretes stool outside the colon wall and an abscess may form, and that may need to be get drained as well.

Scott Steele: Then people who have repeated bouts over time, is there any other things that can happen if you get recurrent bouts over and over and over again?

Michael Valente: It's actually something we see very often is folks will have, like you said, repeated attacks of diverticulitis. Usually these are mild to moderate attacks. They're treated at home. They may have recurrent episodes, something that we call smoldering diverticulitis. Something that kind of never goes away with repeated use of antibiotics. Those patients may ultimately require an elective operation to take care of the problem.

Scott Steele: One of the things that I was talking about or had been reading about in the past is that we divide up diverticulitis into complicated and uncomplicated. I know there's a lot of different definitions that people can talk about out there, but let's focus in on complicated diverticulitis. You talked a little bit about perforation, perforation either meaning that they have a localized abscess where the body forms a boil next to the colon or down into the pelvis. Is there any other type of long-term complications or kind of complicated diverticulitis that can occur?

Michael Valente: If a colon perforates and there's an abscess formation, that abscess may erode itself into other structures in the body, one of them being the bladder, so we have what we call a fancy term colovesical fistula, which is a connection between the colon and the bladder that can happen. Another complication is a connection between the colon and the vagina in the female, a colovaginal fistula. Sometimes the colon can make an abscess and go to the belly wall, a colocutaneous fistula. All of those generally require an operation to cure the problem.

Scott Steele: Yeah, and like other things, when the colon gets repeated inflammation over time, it can have the ability to kind of stenosed or stricture down and you can get an obstruction associated. Mike, one of the things that comes up a lot is the fact that patients will ask me, they'll say, "Hey, every time I get some left lower quadrant abdominal pain, I have that bout of diverticulitis right there." Mike, is that the case that this is always diverticulitis, or what other things could this be?

Michael Valente: It's a good question. Not always. I think we may have a tendency to over treat diverticulitis potentially. It could be something else going on. The best treatment I would say is make sure you go to your family doctor and make sure you've had an up to date colonoscopy as well.

Scott Steele: Truth or myth, I have diverticulosis and not know that I have any symptoms.

Michael Valente: Correct.

Scott Steele: What are the common symptoms that are associated with diverticulosis and diverticulitis?

Michael Valente: Diverticulosis very often has no symptoms, as we just said. A condition of diverticulosis which does occur is sometimes bleeding. We could have gastrointestinal bleeding. Sometimes pretty profound bleeding, which is almost always what we call self-limited. It usually does stop, but it can be quite a bit of bleeding. That is very, very uncommon however. Diverticulitis symptoms usually begin with some abdominal pain and cramping, maybe some nausea, sometimes even vomiting. Usually the patient has a difficulty time eating as well.

Scott Steele: How would a patient really truly get diagnosed with diverticulitis? We talked about the fact that not all left lower quadrant pain is diverticulitis. It could be just irritable bowel syndrome, cramping, diarrhea of other causes. We know all that, but let's just say we want to focus in and say, "I'm going to definitively make a diagnosis of diverticulitis." How does one go about that?

Michael Valente: Nowadays usually that's performed with a CT scan or a CAT scan and that's usually the best way that we can define that there's an active attack of diverticulitis going on.

Scott Steele: Do you have to have a colonoscopy to have a diagnosis of diverticulitis?

Michael Valente: No. Usually when the patient is having an attack of diverticulitis, we would not want to do a colonoscopy in that setting because it could be potentially a little bit dangerous because the colon's a little bit angry. But after the episode of diverticulitis has calmed down, we do recommend having a colonoscopy performed to confirm the diagnosis.

Scott Steele: Mike, what do you make about the patients who say, "I know that you say that I can't necessarily have repeated bouts of diverticulitis, but I got antibiotics, I had some leftover or somebody gave me diverticulitis and I got better." Does that surprise you at all?

Michael Valente: It does not surprise me at all.

Scott Steele: Do we know have a reason exactly why that's the case?

Michael Valente: We do not.

Scott Steele: Yeah. I think that in general there's lots of different things we don't know about the gastrointestinal tract, but it is not unsurprising that people may respond with various symptoms with diverticulitis or not having a condition associated with diverticulitis. The mere fact that you get better with antibiotics, we need to be able to determine what the underlying cause for that is. Speaking more of these truth or myths, let's talk a little bit about the treatment of diverticulitis. Truth or myth, surgery is always needed to treat diverticulitis.

Michael Valente: Myth.

Scott Steele: Let's expand a little bit about that.

Michael Valente: I would say the vast majority of patients that I see in my office do not require an operation. Most of them will get better on their own… sometimes antibiotics may help. Time Bowel Rest we call it. Not pushing the bowel with too much high fiber foods, kind of be a low fiber diet, and just time. Most patients resolve quite well. These are the uncomplicated patients.

Scott Steele: I tell patients a lot of times, the fact that we think about exercise and we know that exercise is good for our bodies. If you want to build up your muscles, you may want to exercise. But with the colon... that exercise for the colon is fiber. Just like if you have a pulled muscle, you may want to hold back on exercise. When you have a bout of diverticulitis, maybe go on low fiber and not high fiber foods. Who does need surgery for diverticulitis?

Michael Valente: Great question. This is probably one of the most complicated office visits I have because there's such a wide spectrum of presentations. As we talked about earlier, the complicated patients are more prone to having a surgery, but not every patient who has an abscess would require an operation. But those folks with repeated attacks, we talked about that smoldering diverticulitis where it never really goes away, those are a good candidate for an operation. People with those fistulas or complications that we talked about will need an operation almost uniformly.

Then there's a small percentage of folks who come into the hospital very sick with a bad perforation or hole in their colon. Those folks usually require an immediate or urgent operation, but those are the minority of patients that present.

Scott Steele: Let's just talk about the elective setting, not the people who are really sick and urgent. What is the actual operation? What do you do in the operating room and what can people expect?

Michael Valente: Nowadays, very often we'll be performing these operations in the laparoscopic approach with the camera and the small incisions. Generally speaking, two to three hour operation. The sigmoid colon is the most common location of diverticulitis in the left lower part of the belly, the sigmoid colon. We remove that section with the camera and the laparoscopic instruments. We reconnect the colon back together through various approaches, and usually the patient on an average can may be expected to stay in the hospital between two to three, maybe four days at the most.

Scott Steele: You talked a little bit about the fact that the sigmoid colon is most common. Can diverticulitis occur in other areas?

Michael Valente: It can occur in other areas, but I would say 90% plus of diverticulitis attacks occur in that sigmoid colon.

Scott Steele: Patients ask me a lot, "I have a problem with my colon. Do I need to have a bag? Do I have to wear a stoma, ostomy, any one of these different terms?"

Michael Valente: Excellent question and always on the thoughts of all the patients. I would say in the elective setting, the vast majority, 99% of patients do not require a bag or a stoma. In the emergency setting, that's a much different situation where the chance of having an ostomy bag are much higher if it's an emergency and it's a life or death situation. But overall, the chance of having a stoma, either temporary or permanent, are very low for an elective operation.

Scott Steele: Let's say I'm going to do whatever I can. I've either had a bout or I'm listening to this and I'm thinking, I need to change around my lifestyle because don't want to have any colon operation. What are some of the lifestyle choices, whether it be diet, exercise or whatever, that can help prevent diverticular disease or diverticulitis?

Michael Valente: Healthy lifestyle, of course, as we discussed, but good eating. High fiber, low fat, and the things that we want to feed the colon are roughage, vegetables, bran, oats, those high fiber substances. Exercise, of course. Reducing the sedentary lifestyle will make us a much healthier overall and this is good colorectal cancer prevention as well.

Scott Steele: You mentioned that in kind of a passing way, but Mike, is diverticulitis, does that have any sort of a connection to cancer? You had mentioned in the past that we need to have a scope on these patients after they recover from diverticulitis. Is it because they have underlying cancer? What's the rationale for that?

Michael Valente: No, not necessarily. They generally do not have an underlying cancer, but what we have to make sure is if the patient has a bout of diverticulitis and they never had a colonoscopy per se, that patient definitely needs a colonoscopy because cancer can mimic what diverticulitis does. It can present very similarly. Also, if that patient had a colonoscopy five, six years ago and now they have diverticulitis, that patient should also get rechecked up with a new colonoscopy just to make sure that there is no underlying cancer.

Scott Steele: But diverticulitis in and of itself is not connected to cancer?

Michael Valente: It is not.

Scott Steele: Huge topic. We could spend probably two hours going over the finer details on this, but what is kind of your take home message for listeners regarding diverticular disease?

Michael Valente: It starts off with a healthy lifestyle, eating well, being active. It's very common. Diverticulosis is seen in the vast majority of patients after you reach a certain age. Diverticulitis is common, but the vast majority of patients do not require an operation. With that being said though, please make sure you follow-up with your family doctor. We need to make sure we have the correct diagnosis, either via colonoscopy to confirm that there is diverticulosis or a CAT scan to confirm that there is diverticulitis. There's no question that you should probably talk to a surgeon if you have repeated bouts of diverticulitis to see what your options are and to see if surgery is something that may benefit you.

Scott Steele: As you know, we like to end all of our podcasts here with some quick hitters. You've been on here before, so a couple of new questions for you. What type of music, if any, do you listen to in the operating room?

Michael Valente: Yeah. I like rock and roll music. I like classical music as well.

Scott Steele: Mike, what's your favorite cartoon character?

Michael Valente: Good question. Well, we've been watching a lot of old school Transformers with my seven year old right now, so probably Transformers from 1984-'85.

Scott Steele: The best advice you can give to someone listening to this that wants to go into surgery.

Michael Valente: You should definitely do it. It's been the best career choice I could ever possibly pick. You'll work hard, but you'll be happy.

Scott Steele: You've told us in the past before what you like about Cleveland, but what's a hidden treasure somewhere in the State of Ohio?

Michael Valente: It's a good question. There is a place in Southern Ohio called the Great Serpent Mound, which is a Native American burial ground of the Hopewell and Adena tribes of Southern Ohio, which not many people really know about, but it's really interesting archeology.

Scott Steele: That's fantastic that you can come up with that off the top of your head. For more information on diverticular disease, please visit Cleveland Clinic's health library at clevelandclinic.org/health. That's clevelandclinic.org/health, H-E-A-L-T-H. To speak with a specialist in the Digestive Disease & Surgery Institute, please call 216.444.7000. That's 216.444.7000. Mike, thanks for joining us again on Butts & Guts.

Michael Valente: My pleasure. Thank you.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.