Diverticular Disease Explained with Dr. Sherief Shawki

Podcast Transcript

Nada Youssef:Hi, thank you for joining us. I'm your host Nada Youssef, and you're listening to Health Essentials Podcast by Cleveland Clinic. We're recording here at Cleveland Clinic Main Campus with Dr. Sherief Shawki. Dr. Shawki is a colorectal surgeon in the Digestive Disease and Surgery Institute here at Cleveland Clinic.

And today he's going to shed some light on diverticular disease, a common condition that affects the large intestine. And please remember this is for informational purposes only, and it's not intended to replace your own physician's advice. Thank you so much for being here today.

Dr. Sherief Shawki:It's always a pleasure.

Nada Youssef:Thank you. All right. Let's start with what is diverticular disease?

Dr. Sherief Shawki:Overall, the bowel is a long tube that works on absorbing nutrients and fluids so the body can benefit from it. And the last part of it, which is the colon, particularly the sigmoid colon, basically it conveys the stool before it comes out through the rectum. So sometimes there is weakness points in this tube. If you think of plumbing, this weak points where the blood vessels traverse the muscular layer creates a weak point through which outpouching the diverticula can happen along that line. These diverticula can stay there and as long as they're not causing problems or symptoms, then nothing is wrong with it.

Nada Youssef:So diverticula is like a pocket or a pouch in your colon?

Dr. Sherief Shawki:Yes. In brief definition, it's out-pouchings through the colon wall. Most commonly found in the sigmoid colon, which is the part of the colon just before the rectum.

Nada Youssef:Okay. Is this a pretty serious disease or is it pretty common?

Dr. Sherief Shawki:Having diverticula or diverticulosis should not be considered a disease on its own because many people are living with it. In fact, if you look at the numbers, about 15% will have diverticulosis. And of these people, 20-25% will get symptoms. And of these 20-25%, only 15% almost will get surgeries.

Nada Youssef:15% will get surgeries?

Dr. Sherief Shawki:Yes.

Nada Youssef:So 15% will have it. And those 15% will have surgeries or of these?

Dr. Sherief Shawki:No, if you see 100 person with diverticulosis, 15% to 20% will have symptoms. And of these people, if you have 100 person that have symptoms from diverticulosis, which could be diverticulitis or bleeding or anything that we're going to talk about later, then about 15 to 20% of these or 25% will have surgery.

Nada Youssef:Wow. Okay. Here comes the hard part. Can you clarify slowly the difference between diverticula, diverticulosis, diverticulitis?

Dr. Sherief Shawki:This is a very good question. So if somebody developed the outpouching, then they have diverticulosis. And to make it easier for the audience, from the medical term Greek, means having the things there, -it is means inflammation. So diverticulosis means the presence of diverticula in the colon. Diverticulitis means inflammation of these diverticula.

Nada Youssef:Wow. So diverticulosis by itself is not harmful at all?

Dr. Sherief Shawki:As long as it's not symptomatic, then the patient should ... We should not call them patients because we can have it, but we don't know because we don't exhibit symptoms.

Nada Youssef:I see. So we can have it, just not know if we have it until we get the symptoms.

Dr. Sherief Shawki:Exactly.

Nada Youssef:Can we talk about the symptoms of something like diverticulitis because that means inflamed, right?

Dr. Sherief Shawki:Good question. Diverticulosis can present itself in a variety of ways. Number one, it can be as simple as abdominal pain, cramps because the muscle layer in the sigmoid colon contracts a lot. So you get the sharp crampy abdominal pain that can happen with food or with meals. And it's usually in the left lower quadrant of the patient, where the sigmoid colon lives or where the sigmoid colon exhibit the symptoms.

The second thing, which is most commonly known among people is the diverticulitis, the inflammation. And basically abdominal pain more in the left lower quadrant, maybe fever, maybe chills as low as this and the extreme of the spectrum can be fever, extreme abdominal pain that provoke the patient or prompt the patient to go to the hospital and they may get even emergency surgery.

And I would like to say more about the spectrum of the symptoms and what can happen with each one, but I knew we are having a section for treatment later, so I'm going to stop here and continue with the symptoms and then when we go to the treatment we can continue then.

The second one is diverticular bleeding. Where this outpouching when you look at it, it is a very weak part of the muscle layer. It is not full thickness of the bowel. It is just two very tiny layers of the bowel, which means it's not protecting. So if there is blood vessel in this outpouching that gets eroded, it will bleed, hence diverticular bleeding.

Then there is longterm complication of the diverticulitis and basically, they can be the chronic or the longterm inflammation on and off, on and off, or subclinical, which means symptoms are subtle and vague but happening for long time. Then what can happen is the chronic diverticular inflammation can result into deposit of lots of scarring tissue. That scarring causes called fibrosis and this we'll cause a narrowing of the bowel lumen which cause a stricture. That's the narrowing which cause obstruction.

So the second one in the spectrum could be diverticular bleeding, which basically, if you look at this outpouching, the diverticula which is just outpouching, this is not a full thickness of the bowel. It's very tiny two layers of the bowel, which means any blood vessel in these two layers is subjected to get eroded and traumatized. When this happens it will cause bleeding, hence diverticular bleeding.

The third part of it is a sequelae or a consequence of the longterm inflammation, the diverticulitis. Either on and off, recurrent diverticulitis comes, heals and then relapse again. Or subtle subclinical asymptomatic, it's like pain there on and off but not really strong to prompt the patient to go to the ED.

So the chronicity of inflammation when result into A, lots of scar tissue deposition which will result in narrowing of the colon, also known as stricture. And this will cause obstructive symptoms. The second one that with the small slight hole called perforation in the diverticular, that creates a tunnel that burrows through the colonic wall. And this tunnel may open into whatever nearby structure, could be urinary bladder known as colovesicular fistula, can open through the vagina, colovaginal fistula, can open through the bowel, colo-enteric fistula or colocolic fistula.

So basically whatever this tunnel that originate in the colon opens into, will result into the medical term known and fistula and this prompts surgical management. And so these are the things that are resulting from this in the spectrum of diverticulitis. And last but not least, is the most commonly one encountered as the absence because diverticulitis will result from a macro or micro hole perforation in the colon.

This perforation can be sealed and can be simple or it can be basically large. When it is large hole, it will result into dissemination of fecal material, which is in the colon, into the abdominal cavity, which should not exist there. This will result into aggressive inflammation that will ultimately result into the abscess, hence the diverticular abscess.

Nada Youssef:So does this present itself as blood in stool?

Dr. Sherief Shawki:The bleeding may result into bloody bowel movement.

Nada Youssef:Oh, okay.

Dr. Sherief Shawki:Inflammation only on and off, may result into blood in stool that can be seen, overt, or can be not seen, occult. The abscess would result into with severe abdominal pain that the patient will not tolerate or the person at this point will not tolerate and will go to the ED and the workup will take place at this point.

Nada Youssef:So let's talk about diagnosis. What does the doctor's appointment look like if someone has that disease and they show up, what kind of tests are being done as well?

Dr. Sherief Shawki:This is an excellent question. So based on what I explained previously, you can tell that there are symptoms that can prompt an office visit and there are symptoms secondary to a sequelae of diverticulitis that can prompt an emergency department visit. So if there's abdominal pain which called simple uncomplicated diverticulitis, which means that it's inflammation of these diverticula, but it hasn't resulted in any of the complication of the diverticular disease. So the patient will go to the primary care doctor, family doctor or the surgeon or colorectal surgeon.

Based on this, we don't have to scan them. We can rely on the symptoms. I just want to highlight that here in Cleveland Clinic we treat humans, human bodies. We don't treat reports or CAT scans or numbers. So we'll listen to the patient complain and we can differentiate and after we conclude that the diagnosis is simple diverticulitis, usually we prescribe an oral antibiotic for seven to 10 days and follow up with the patient afterwards, make sure that the attack or the episode had healed.

The other part of this is severe abdominal pain for diverticular complication, which is most commonly is that complicated diverticulitis. And usually this require a visit to the emergency department because at this point we need to perform a CT scan of the abdomen. For those who don't know, a CT scan is an X Ray that medically show us what's on outside through the inside of the body so we can delineate and characterize the pathological process of the disease.

And usually we can tell that there's inflammation in the sigmoid colon where the perforation had occurred and we can tell if there is an abscess with it or there is no abscess with it. Also we can tell if there is suspicion of a fistula, which is the tunnel between the colon and another organ nearby. We can suspect that from the CT scan.

Last but not least, if there is bleeding, definitely the patient will go to the emergency department. Among the workup of the bleeding after resuscitation and proper stabilization of the patient, then the workup will include colonoscopy to make sure what is the source of the bleeding among other radiographic battery of investigation that can happen, through diagnostic as well as therapeutic.

Nada Youssef:So what would warrant an ed visit could be bleeding, extreme abdominal pain. Is fever a part of this diagnosis as well?

Dr. Sherief Shawki:Fever is a sign.

Nada Youssef:Okay.

Dr. Sherief Shawki:It's the clue that there is something bigger than just simple inflammation. It can be low grade with simple, but usually with abscess, they usually shoot up high.

Nada Youssef:So how long do flare ups usually last and do they ever go away on their own?

Dr. Sherief Shawki:So if it is a simple diverticular disease or simple diverticulitis that's uncomplicated, it takes few days. If it is a complicated diverticulitis, it also takes few days up to a week, but usually this requires admission of the patient because the difference is oral antibiotic versus admission in the hospital, nothing by mouth, complete bowel rest and IV and intravenous antibiotics, antibiotics by the vein by the vein till we have more powerful treatment for basically, to cool off and calm down the inflammation. And then plus or minus, if we're going to do interventional procedure for the type of pathology that we are dealing with.

Nada Youssef:And we'll get a little bit more into treatment here in a second. But I wanted to ask you first about risk factors that are associated with this disease and if it is more likely for someone that has Crohn's or IBD or some kind of gut issue, are they more likely to get that disease?

Dr. Sherief Shawki:So I will take this question and divide into two components. Component number one, the risk factor of the study is the largest population of studies that have tried to study the epidemiology of diverticulitis found that A, it increased with age. So by age of 80 about 80% will have had diverticulosis.

Also, the older the age, the more susceptibility to get diverticular attack or diverticulitis or diverticular bleeding. This is number one. Number two, factors associated with diverticular disease is smoking, high fat diet, red meat, a sedentary life and obesity. These are factors that are known, have been mentioned in the literature that they are associated with diverticular disease.

Nada Youssef:Okay, so it's a treatment. I know it sounds like there is mild diverticulitis and there's more severe. What kind of treatments would you be doing for both?

Dr. Sherief Shawki:Again, it depends. As I explained, the spectrum is large, so this is the time that I'm going to conclude for the audience what happens and how we deal with it. So basically if it is diverticulosis, which we said the presence of diverticula, no symptoms, nothing. If it is diverticular diverticulitis, then here is the break point. Is it simple, uncomplicated diverticulitis? That's inflammation of the diverticula, then this can be treated as outpatient.

Some doctors prefer to recommend for the patient to have a clear liquid diet, not high volume light, plain diet and oral antibiotic for seven to 10 days and follow up to make sure that it resolved. If it is complicated diverticulitis, which means there is perforation, this perforation can be just a perforation without abscess. This requires in my opinion, admission to the hospital, stronger antibiotic treatment, which is antibiotic by the vein, bowel rest and then we start feeding the patient until they feel better and then they will send them home.

If it is a complicated diverticulitis plus abscess, then if this absence is accessible for x-ray, then we put a drain in it to control the infection. The concept is basically putting the straw in the juice box. So we try to put a drain. If that absence is accessible safely for the radiologists, they put the drain in, that drain usually stay there for a few days up to a week. With the antibiotics in the vein and and then based on how the patient perform or how their clinical course dictates, the treatment of course or take place.

Ultimately the drain is to come out and we feed the patient and we see how things are. If there's bleeding, as we said, this requires emergency department visit and it's some sort of emergency situation that we have to deal with to stabilize a patient, resuscitate and then investigate the cause of that bleeding.

Any complication usually will ultimately result into surgical management and this is when they come and they come and be referred to me or to us here. That being said, some people with simple diverticulitis, they are referred to us and we usually talk to them about the disease, just making acquaintance and we don't offer them surgery at this point.

Nada Youssef:So when is surgery offered?

Dr. Sherief Shawki:When there is a complicated diverticulitis, when there is a frequent recurrent disease, relapsing attacks of diverticulitis. Another one, very much important component, if a person who is, we call them immunocompromised or immuno-suppressed. This is a person with a transplanted organ, a person who has this other medical disease that require consuming constantly steroids or immunosuppressant.

These patients, the immunity system is not well equipped to defend the body against the diverticulitis. Hence the progression of the disease can be faster and result into catastrophic complication. For these patients, we offer surgery sooner than later. We don't actually treat them like the normal competent immune system people.

Nada Youssef: So I want to jump to diet really fast. First of all, I want to talk what to eat when you have this disease because I've read that people who develop diverticulitis may not have good enough, good bacteria in their gut. So does something like probiotic yogurt, is that helpful?

Dr. Sherief Shawki:So adopting healthy lifestyle is good. There is no proven evidence that this may prevent or proof. It all depends on how the studies are designed and what the outcomes. But usually when there is an acute attack of diverticulitis, we want to get the colon little bit of a rest.

However, after that, the five main fact that we talked about, so we try to give high fiber diet after the attack is done, we try to minimize fat, we try to minimize our red meat. There is also a theory about nuts, seeds, popcorn and corn that this may precipitate an attack. In fact, they do not.

Nada Youssef:They do not.

Dr. Sherief Shawki:So I always tell my patients, there are certain things in life that you are your own doctor in it, so you have to try. And one person will tell me, I cannot eat almonds. It irritates my bowel or it will aggravate my diverticula. And some other person will tell me I can eat anything and it doesn't really matter.

So each person has to be his or her own doctor in that, they have to be engaged, they have to feel what's causing the trouble in the gut and what's not causing the trouble in the gut in their diet.

Nada Youssef:So listen to your body and go from there. But are there any foods that we are supposed to stay away from to prevent any kind of inflammation?

Dr. Sherief Shawki:In my mind, no.

Nada Youssef:Okay. All right, good to know. So we've talked about complications and I've read that about 25% of people with acute diverticulitis develop complications. So what do these complications look like? It could go from the bleeding and things like that, but are they due to not treating the disease early or is that just kind of depends on every person?

Dr. Sherief Shawki:It depends. And as I describe it or explain it in a simple form, longstanding inflammation, regardless complicated or non-complicated can result into these tunnels, which known as the fistula, can result into the deposition of scarring tissue because long inflammation and this can result into the narrowing and obstruction or can cause basically the bleeding.

And these are the long sequelae or longterm consequences of complicated of diverticulitis. And sometimes I see patients coming to me and their first complain that they're having air while they are urinating, which is called fistula between the colon and their urinary bladder.

So one of the sign that when they pass air while they are peeing this mean there is a communication with part of the gut. So sometimes the first time that they come with is this. So they haven't exhibited signs before. And that's what led me to say, it could be subtle that the patient can just live with it and tough it out without going to a doctor or going to the emergency department.

Nada Youssef:Okay, great. And then my last question for you is prevention. So if you could tell our listeners if there is anything we could do to prevent diverticula, diverticulitis, diverticulosis or prevent them from becoming infected. Anything that we can talk about, cause it doesn't sound like there's a cure, right? No cure for this. So what kind of lifestyle do we need?

Dr. Sherief Shawki:So if we remember when we talked about the fact that associated with diverticular disease, if you look at them, they are smoking, obesity, high fat content and diet, high red meat and sedentary lifestyle. And if you look at this bundle, you're going to find them the same in heart disease, you're going to find in the same in lung disease, you're going to find them all over the, across the board with many other diseases.

So briefly adopting a healthy lifestyle with moderation, everything will impact, not only diverticular disease, will impact our heart health, our lung health, our general body health. Also consuming lots of processed fat, processed carbohydrates, sorry, also will result into lots of gut troubles.

So yes, if we have tried to minimize, I'm not going to say to cutoff, minimize and be moderate with the fat content, junk foods, red meat, smoking, being healthy and walking at least twice a day or once a day, then yes, this will improve diverticular disease, which are the focus of today and overall, our health in life.

Nada Youssef:Excellent. I'm going to ask you one last question. With high fat, I want to pick on that a little bit. So when you talk about high fat, is there good fat versus bad fat? If someone in my family member has this, is olive oil a bad idea versus-

Dr. Sherief Shawki:It's a good idea.

Nada Youssef:Yeah. Is there a good fat and bad fat that we should stay away from?

Dr. Sherief Shawki:So the olive oil, that's a good product that can be used in cooking instead of butter, for example. Okay. So this is an example of things. When you're eating meat, you don't have to eat lots of the fat around the meat or chicken or turkey. So all these things, you don't want it eat it. You want to actually try to avoid and minimize it.

Also the carbohydrates and the healthy pattern of eating when somebody basically fast all day and then all of a sudden they come and indulge on a heavy meal by night, then you're switching your metabolism to starvation the whole day. So that meal that you're going to eat, your body will hold on every single cell or every single component in it because it's in starvation mode and this is how we gain weight and we say, well, I'm not eating all day long, but your eating pattern is wrong.

Nada Youssef:That's a very good point because there's a lot of people that do intermittent fasting. But you're saying the first meal of the day should be, stay away from fat, stay away from carbs and make it a healthy meal?

Dr. Sherief Shawki:It depends.

Nada Youssef:Okay.

Dr. Sherief Shawki:It depends because there are lots of diet regimens that switch the metabolism, like keto diet, for example, fat is allowed, but there is no carbs completely. But since fat is allowed, don't go and eat all the fat you can, but you need it in moderation and try to eat the healthy fat. This will open your mechanism to use the fat in your body towards creating energy because there is no carbohydrates available.

Nada Youssef:You're full of information today. That was very, very pleasurable. Thank you so much for being here today and if you'd like to schedule an appointment with the Cleveland Clinic's Digestive Disease and Surgery Institute, you can call (216) 444-7000. And for more information on diverticular disease, please visit clevelandclinic.org/diverticular.

And to listen to more of our Health Essentials podcast from Cleveland Clinic experts, you can visit our website@clevelandclinic.org/hepodcasts or you can subscribe on iTunes. And for more Cleveland Clinic news, health tips and information, make sure you follow us on Cleveland Clinic, just one word, Facebook, Twitter, and Instagram. Thank you so much. We'll see you again next time.