Intestinal problem can be severe enough for surgery

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with a podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Diverticulitis becomes more of a problem for people over age 40.

And today, we'll learn about ways to reduce that risk with Dr. Kristina Go. She's a surgeon at Upstate who specializes in colon and rectal surgery.

Welcome back to "The Informed Patient," Dr. Go.

Kristina Go, MD: Hi. Nice to see you again.

Host Amber Smith: Let's start by going over the signs and symptoms. How would a person know that they have diverticulitis?

Kristina Go, MD: That really depends on the severity of their symptoms. But generally speaking, patients who have lower abdominal pain, particularly in the left side of their abdomen or belly, associated with fevers and chills, make me more suspicious that they might be having a diverticulitis attack.

Host Amber Smith: What is on the left side? Why would it be on the left more so than the right?

Kristina Go, MD: In the Western world, the most common site of colonic diverticulitis, as in diverticulitis within your large intestine or colon, tends to be in the last part of the colon, called the sigmoid colon, and that tends to be on the patient's lower left side.

Host Amber Smith: So what are the things a doctor might do for someone who's got abdominal pain on the left side to determine if it's diverticulitis or if it's something else?

Kristina Go, MD: The first things that I would approach the patient with, are if they're very sick and look ill, or if they seem to be having pain that is manageable. Barring them looking very sick and ill, really, the way that I would start to approach this patient is asking them a little bit more about when they started to have these symptoms, anything they've tried to make it feel better or worse, basically getting a good history and then, after that, a physical exam to further find out whether this is diverticulitis or something else.

Host Amber Smith: Are there things that have to be ruled out?

Kristina Go, MD: Yeah. Certainly when you're starting to think about diverticulitis, and we're talking abdominal pain and fevers, that's a pretty broad range of things that could be happening within a patient.

So, again, I try to sort things out when I approach a patient. Are they very sick, and do we need to do something more emergently, or are they getting through an episode that is less severe, and after treating it, do we need to think about what else might be going on?

What I mean by that is after a history and physical exam, a patient might end up also getting lab work. They might get some imaging studies, either a CT scan, maybe even an ultrasound, and then after, we roll out other possibilities.

For example, in a female patient, there might be gynecological reasons to have these symptoms, or if it might be something else, then we would treat that patient differently than whether or not they had diverticulitis.

When I think about it as a colon and rectal surgeon, though, and I have a patient who might have diverticulitis, I get them through this episode and then ultimately, in about a six-week period after they are feeling better, I would recommend a colonoscopy to rule out something like a colon or rectal cancer.

Host Amber Smith: Now I've heard of diverticulosis. Is that the same thing as diverticulitis?

Kristina Go, MD: This is an excellent question because they sound very similar, and they are related to each other, so let's go through a couple of definitions to tease out why you might hear one term, and a physician might use a different one.

Diverticulosis is actually just outpouchings or thinning areas of, in this case, the colon wall, that can occur in a patient's body. So when you are told, say by your gastroenterologist or by another type of doctor, that you have diverticulosis, that's just the presence of this anatomical outpouchings.

When inflammation or microperforation, as in something that you might not see by the human eye, or even a visible perforation occurs, that's essentially what diverticulitis is.

So it's that inflammation and infection of the colon that can occur when you already have diverticulosis.

Host Amber Smith: So do you have to have diverticulosis in order to develop diverticulitis or not necessarily?

Kristina Go, MD: That's correct. Really, the definition of having diverticulitis is that you've had this inflammation or perforation of your diverticulum, or diverticulosis, so that's why when you hear that, they sound very similar. They're very large medical terms, and they can sometimes incorrectly be used interchangeably.

Host Amber Smith: Now, do primary care providers generally treat patients with diverticulitis, or at what point might they send someone to a colon and rectal surgeon like yourself?

Kristina Go, MD: A lot of the times, the way that I think about a patient with diverticulitis goes back to the severity of their disease, so perhaps with a patient's first episode of diverticulitis, particularly if it is not very severe, this can be treated by a primary care physician with antibiotics.

Ultimately patients that come to me for further workup might be seeing me because they need a colonoscopy after their diverticulitis episode, or they might be talking about surgery, and we can go into different reasons why a patient would need surgery, either in an elective -- what I mean by elective is a scheduled manner -- or in an emergency manner.

Host Amber Smith: How do you differentiate between a mild case and a more severe case?

Kristina Go, MD: We do have several ways that we approach how diverticulitis presents in a patient. We can talk about mild and severe, but I'd like to take a step back and actually use two different terms.

So, what I say is uncomplicated diverticulitis means that you might see inflammation of the colon that doesn't show a free hole in it, which you might see on either CT scan or based on a patient's physical exam findings. And often that can solely be treated with antibiotics, and the patient gets better and doesn't necessarily need a surgery in the future.

Now, complicated diverticulitis really has a whole host of things that we are looking for in a whole host of categories. So that can mean that a patient might have had a hole in their colon, but the body has been able to wall it off, and instead of having poop or pus sort of free-floating in the the abdomen, you have a pus pocket or an abscess that can be treated. That could also mean a free perforation, like I just said, where unfortunately that's an emergency surgery where somebody might need to be brought to the OR (operating room) within hours of me seeing them.

And then there might be some long-term complications to cause complicated diverticulitis. And that might mean that the colon, while trying to heal in the past, might be narrowed or completely blocked or can cause an abnormal connection to other surrounding parts in the body. That abnormal connection is called a fistula, and so those patients might say, "You know, I notice either passing air or feces in my urine or having recurrent UTIs (urinary tract infections) because their colon and bladder are now abnormally connected to each other. Or in biologically female patients, they might notice a lot of gas or stool coming from their vaginal canal. That would be called a colovaginal fistula. So, we're talking about complicated versus uncomplicated.

When I think about severe, I also think about that whole free perforation where somebody's coming in with, what I would determine is sepsis, and they have very severe abdominal pain. They might have a high temperature and a high heart rate, but a low blood pressure. And when we try to press on their belly, they're so exquisitely tender and in pain that they cannot even withstand being bumped or being jostled a little bit.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and I'm talking with Dr. Kristina Go. She's a surgeon at Upstate who specializes in colon and rectal surgery, and we're talking about diverticulitis.

Do we know what makes one person more susceptible than another to diverticulitis?

Kristina Go, MD: Unfortunately, we really don't. The studies tend to say, "Oh, well what risk factors can we associate with patients that have diverticulitis?" So rather than finding a cause of it, we've noticed that patients who adhere to more of a red meat, or a Western, diet, which really is defined by probably low fruits and vegetables and low fiber, patients who have low physical activity, are considered obese or have a high waist-to-hip ratio. Those characteristics are more associated with having an episode of diverticulitis.

Other things that have been associated with diverticulitis include tobacco use, chronically using an over-the-counter pain medication called nonsteroidal anti-inflammatory drugs, or NSAIDs -- so that includes your Aleves, your ibuprofens -- if you have to use steroids on a long-term basis or even opioids.

As with everything, there seems to be a genetic component because it seems that if you have a sibling who's had diverticulitis, you're more likely to also have diverticulitis. That's hard for me to say because at least when you're siblings, it's pretty likely you have the same environment growing up, so that's very unclear right now, what makes somebody more susceptible.

Host Amber Smith: Why are people more likely to develop this after the age of 40?

Kristina Go, MD: I think this probably has to do with just having age sort of work against you. A lot of the theories for why the outpouching, or diverticulosis, forms has to do with how the colon wall is made.

Structurally, if you take a cross section of your colon, the strength of the wall is not uniform. And then to add to that, there are areas where the blood supply has to actually penetrate through the different layers of the colon in order to feed it blood. And so those are already inherent areas of weakness that all of us develop, or live with, because of how our colon is.

And then we suspect that the way that your poop either moves very quickly, or in this case, slowly, through your colon can also contribute to those weaknesses ballooning out. This is how we think diverticulosis or diverticula form. Why somebody develops diverticulitis is still theoretical at best. We have several different theories. One of them is the idea that maybe the colon is chronically inflamed and just not in a way that is noticeable to the patient. The other is the idea of trauma, so you might hear some patients or providers say, "Well, avoid seeds and nuts." And the idea is that maybe there's a hard piece of stool that gets stuck in these outpouchings and erodes through. We haven't been able to prove that with observational studies, and I'll get into that a little bit more in terms of how to prevent diverticulitis.

Kristina Go, MD: And then there's this other theory that the microenvironment of where the diverticula are just doesn't have as good of oxygen supply, so the idea is because you don't have enough oxygen, and there's what we would call a low-level area of ischemia, or lack of oxygen, maybe that makes that area more susceptible to getting a hole or a microperforation.

Host Amber Smith: For someone who has a mild case of diverticulitis, is this something that can be cured, or is it something that they're going to live with, and it'll recur?

Kristina Go, MD: Unfortunately, in the absence of taking out the piece of colon that is susceptible to diverticulitis or has had diverticulitis in the past, there is a high likelihood that you're going to get diverticulitis again.

And with each subsequent episode, the likelihood of you getting another episode goes higher and higher. Now, that doesn't necessarily mean that you're going to have this very severe case with each episode, though. What we have seen is that when you have that free perforation, where poop or pus are free-floating in your belly and need that emergency surgery, that scenario more likely happens on a patient's first episode of diverticulitis.

It's not to say it can happen in a subsequent episode. It's just what we've seen in terms of patterns. But you could have that mild, uncomplicated diverticulitis and be treated with antibiotics or changes in diet during that episode and avoid surgery. That is really what we would consider a soft indication to take out the colon.

Host Amber Smith: So I was going to ask what surgery would involve? You remove part of the colon?

Kristina Go, MD: If I'm seeing a patient who either has had complicated diverticulitis, or they've had simple but recurrent diverticulitis that has now become lifestyle limiting, the workup would include making sure they have an up-to-date colonoscopy to make sure that this is truly diverticulitis, to make sure that other parts of their colon don't have colon cancer that we need to be thinking about.

And then I counsel the patient about taking out the portion of the colon that has been previously affected, and in the Western world, that is more likely to be that sigmoid colon or the very last part of the colon.

Host Amber Smith: So when you take out that part, you, I guess, have to sew the two ends together.

Kristina Go, MD: Yeah, that's correct. Absolutely. So, in an elective setting, as in something where we've planned it out and it's scheduled, I will take out the portion of the colon that is affected, and then the remaining colon is basically placed from point A to point B together, and that reconnection site is called an anastomosis.

Host Amber Smith: And so you sew it back in place; does the tissue grow back together so that it's secure and there's no leaking?

Kristina Go, MD: That's correct. And, of course, with every type of intervention that we do, there is a risk of complications, so when I talk to patients about surgery for the colon, either in the setting of diverticulitis or otherwise, I do tell them that there is a risk of a leak at the reconnection site.

For scenarios of diverticulitis and taking out the sigmoid colon, I usually quote them a 5% to 7% chance of anastomotic leak.

Host Amber Smith: And let me ask you about colostomy. Is that something that is a necessity for these patients?

Kristina Go, MD: That really depends on the scenario in which I would be offering a patient an ostomy.

So let's take a step back in terms of the term ostomy.

Ostomy really means making a hole in a hollow organ, so listening to the prefix when you hear terms like urostomy, gastrostomy, colostomy or ileostomy gives you a clue to what part of the anatomy this hole is being made into.

For example, when I use the term colostomy, and I'm making a colostomy, what I'm doing is making an incision through the abdominal wall and feeding a portion of the colon or large intestine through that, such that the patient will have poop going through that and being captured in a bag.

Whereas if I'm using the term ileostomy, what I'm saying is that I'm making a hole within the terminal ileum -- that's the last part of your small intestine -- bringing it again through that incision I made in the abdominal wall. And that's really where the portion of bowel that's capturing the poop is being created.

You might be asking, well, what are the scenarios in which I would be making a colostomy in the setting of diverticulitis?

Usually the clinical setting that I would be considering a colostomy is in that patient who comes in very, very sick and septic and needs emergency surgery. And in that case, there might be too much inflammation or other injury to the colon that might make it unsafe for me to be able to place point A and point B together after taking out the area of the colon that has been affected. Another scenario in which we might be considering an ostomy is in an elective setting where I might place point A and point B together, I might see that there's a leak that I need to fix while still in that OR and fix it. But to protect that new connection, because it's at a higher risk of leaking than that 5% to 7% that I quoted, I might protect it by bringing up a loop of the small intestine to basically divert the poop from going through that new reconnection site and avoid that whole septic or abdominal infectious picture.

And if I'm using the small intestine, it's most likely the last part of the small intestine, called the ileum. And so that's why you might hear a colorectal surgeon or a surgeon use the term ileostomy in that setting.

Host Amber Smith: Are those sometimes temporary?

Kristina Go, MD: They tend to be temporary. A lot of the times, if you're having a colostomy because of that emergency surgery, they're a little bit more difficult to put back together, but certainly possible. In the setting of an ileostomy, they tend to be a little bit easier for us to put back together because No. 1, it's plans, and we're bringing up both the upstream and downstream ends, so it's easier for us to find. A lot of the studies, whenever you ask general surgeons and colorectal surgeons how often are ostomies reversed has a lot to do with a surgeon's practice pattern and how comfortable they are in putting them back together.

They tend to more likely be put back together if a patient is then referred to a colorectal surgeon, but general surgeons also know how to do this and are very well versed in it as well.

Host Amber Smith: In terms of prevention, I know you're going to tell us that drinking adequate water and eating a high-fiber diet are important, but getting more specific, how much water does a person need?

Kristina Go, MD: It really depends on the patient, but what I tell patients is, trying to get at least 64 ounces of fluid in every day and taking in at least 30 grams of dietary fiber can help the colon be healthier. Other things that can help in preventing diverticulitis are just really what you hear from many different doctors in terms of your overall state of health. So a high-fruit and -vegetable diet, regular exercise, avoiding smoking -- those are the main things that we've seen are associated with less episodes of diverticulitis.

Host Amber Smith: Let me ask you, does coffee, do soft drinks, count as fluids?

Kristina Go, MD: So while they're not ideal, they do count as fluids. You want to keep in mind that soft drinks with caffeine or coffee or teas do have a diuretic effect. So the whole idea of having a healthy colon is to, part of it is to, prevent constipation. So you are trying to hydrate yourself, and sometimes these diuretic drinks can actually make you urinate more and potentially dehydrate you or be less hydrating than, say, your good old bottle of water.

Host Amber Smith: Now, some people, it's a challenge to get enough fiber. Do the supplements help that you can get over the counter at the pharmacy?

Kristina Go, MD: Absolutely. What I do recommend, and I think everybody I know does it as well, is look at your powdered fiber supplements: your Metamucils, your Benefibers, your Konsyls. The generic terms would be psyllium husk powders, sometimes wheat dextrins. In our current diet, and I am also guilty of this, I'm probably not getting 30 grams of dietary fiber, even if I try very hard to eat a salad and only stick to bran, so I take a tablespoon of one of those types of supplements in the morning with my coffee to help me reach that 30-gram goal.

Host Amber Smith: Before we wrap up, let me ask you about nuts and seeds. Are those forbidden to be eaten by people that are prone to diverticulitis?

Kristina Go, MD: So, not necessarily. The best research that we have seen, it's not very good quality research, but what we've asked of a whole population of patients is to keep a food diary and basically see what they most likely eat and then correlate it with how often these patients are getting diverticulitis.

Now remember, an association doesn't mean causation, so it seems like the patients who more regularly ate popcorn or nuts or seeds seems to have less episodes of diverticulitis. And that could be for all sorts of reasons.

Eating nuts, seeds and popcorn are healthier foods, and so they might just have a healthier lifestyle to begin with. Whereas I do have patients who do tell me, "You know, when I eat this, I notice that I get another episode of diverticulitis." So the science is not robust, and therefore, my advice to them is not particularly sophisticated.

Really, what you want to make sure of and make note of is what are these foods that are triggering you? And if you notice that it is a trigger, avoid them. Otherwise, you don't necessarily need to avoid nuts and seeds for the rest of your life if you notice that that hasn't had any correlation to your episodes of diverticulitis.

Host Amber Smith: Dr. Go, thank you so much for your time. I appreciate it.

Kristina Go, MD: Oh, you're very welcome. Thank you. Have a good day.

Host Amber Smith: My guest has been Dr. Kristina Go. She's a surgeon at Upstate specializing in colon and rectal surgery.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.