Transcription:
Current Management of Diverticulitis

Melanie Cole (Host): Diverticular are small pouches that bulge outward through the colon and large intestine, if these flare up or become infected, it can be quite painful. My guest today is Dr. Marjun Philip Duldulao, he's a colorectal surgeon, and a member of the medical staff at Palmdale Regional Medical Center, as well as a member of the medical staff at Keck medicine of USC. Welcome to the show, Dr. Duldulao, what is diverticulitis? People hear about this, but they're not quite sure what that is.

Dr. Marjun Philip Duldulao (Guest): Sure, as you explained before, Melanie, that diverticular disease or these out pouches that develop over time, in the colon mainly. And basically, what diverticulitis is inflammation of these out-pouching’s within the colon. The most frequent time that you see this are mainly in men and females, age greater than 50 or 60 years old, but they could affect patients at any time in their life, especially if they have a family history that predisposes them to diverticular disease and diverticulitis, or in certain risk factors, such as people who have a high meat content in their diet.

And so, diverticulitis presents with a host of symptoms, which mainly, it presents with fever, left lower quadrant, lower abdominal pain, sometimes intermixed with either diarrhea or constipation, but the most profound symptom is mainly, left lower quadrant, abdominal pain, in these patients. Females and males have equal predilection for this disease, and it's rare in patients who are younger than 30, but some other…also symptoms that are manifested along with diverticular disease could also be the development of blood from their stools, as well as potentially even fistulas, which are communications between the bowel and other organs, like the skin or vagina or even the bladder.

Melanie: So, you mentioned a genetic component to these, is it something that if one of your parents had, you should get checked? Would that be seen somewhere? Is there a screening? Would you even know before you get that first painful flare up?

Dr. Duldulao: So, the genetic component is still sort of yet to be elucidated, but we do know that in families, especially if the families share the same sort of diet, that these patients are more at risk for developing for symptoms that could contribute to their diverticulitis or consistent with their diverticulitis, as well. And so, there really is no way to sort of check, but there are ways to help change, and hopefully even prevent episodes of diverticulitis, especially if it's fairly common amongst various family members, either mother, father, aunt, uncle and even children and such. And one of those changes is also a diet change as well including higher fat, higher fiber content, as well as taking lots more hydration compared to and describing more to an Eastern diet which is vegetable based, as opposed to a Western diet which is high in red meat.

Melanie:  And, Dr. Duldulao, certain people that might have occasional flare ups of diverticulitis might also suffer from Crohn’s or irritable bowel disease, and then so they can't have all of that fiber. What do you tell them about dealing with sort of chronic intestinal diseases?

Dr. Duldulao: So, that is also one of the differential diagnoses that needs to be determined, whether these patients have flares from diverticular disease or diverticulitis versus Crohn’s or ulcerative colitis. And one of the best screening methods to determine whether a patient is afflicted with one or the other would be to get a screening colonoscopy. If patients do have chronic inflammatory maladies, not only just Crohn's and ulcer colitis, but also irritable bowel syndrome, and such an issue see their gastroenterologist for further workup, and also, management of the symptom. And usually, after managing those symptoms and having those under control, we can differentiate between whether the patient has symptoms from IBS, chronic inflammatory bowel disease, such as Crohn's or ulcerative colitis, and differentiate that from their diverticular symptoms, which I stated earlier are mainly left side or left lower quadrant, abdominal pain like symptoms.

However, there are occasions where it is hard to differentiate and I think those are patients that warrant further investigation and consultation with specialists such as the colorectal surgeon, to help determine which symptoms and factors are contributing most to the patient's discomfort, and such, and even a surgical intervention can help out with those patients as well.

Melanie: So, if you've had one flare up, does that put you at risk then? You know that you could possibly have another and you need to watch out for some of those symptoms.

Dr. Duldulao: So, we're learning that diverticular disease is actually a spectrum disease, people only hear about the worst of these symptoms, either the patient comes in with a terrible abscess or they have perforation of the colon. They require surgical management at that time because of the emergency, urgency of the situation.

However, as we're learning diverticular disease is actually functioning over a spectrum. Some people may have diverticulitis and may not even know it, and they just present with just mild lower abdominal symptoms, which they just attribute to either gastritis or some sort of enteritis or intestinal upset. And, the other extreme would be patients who present with emergencies with gross chronic…gross infection with abscesses and perforation and such. And so, as we're learning that this is a spectrum, patients could present either asymptomatic or with mild symptoms or even further than that, it’s chronic symptoms, and even further than that is emergent symptoms which require an operation. And so, the management of diverticular disease really depends on how much the symptoms are also affecting a patient lifestyle, and that's also part of the consideration in discussion. If patients have mild symptoms and it’s their first episode, usually these can be treated by either pain management or even with I.V. antibiotics or oral antibiotics. And most of the time about 50 percent of these patients will resolve with just this type of management.

Furthermore, the most emerging cases usually present with their first or second episode of diverticulitis, but if patients usually have four, five, six episodes of these left lower quadrant abdominal pain, the risk of having an emergency surgery is less, however as the history sort of repeats itself if you have multiple episodes of diverticulitis, it's likely that you'll have another episode sometime in the near future. Usually about three quarters of these patients recur with recurrent symptoms three years after their last or previous episode.

Melanie: So, are there certain foods as they're trying to increase their fiber and get more hydration, certain foods that they should be avoiding, food with seeds, because we hear about those sorts of warnings, is that the truth?

Dr. Duldulao: I think this is also coming into the realm of mythology in a way, it used to be that we thought that seeds were the main reason that that causes the inflammation in the Diverticular, the outpouchings of the colon, but now that is sort of come into suspect, and actually has been proven to be debunked. It's not necessarily seeds, but basically the fact that you’re having to transmit a hard and very difficult to transit hard stool that creates or causes more problems for patients with diverticulosis and can lead to diverticulitis. And so, the benefit about having a high fiber, higher fiber intake is that fiber allows for quicker transit of the feces through the colon, and it makes the stool much softer. And so, the colon doesn't have to squeeze as hard to transit the feces from colon all the way down to the ultimate end, into the toilet, but the other benefit about higher fiber intake is that higher fiber intake also bring these short chain fatty acids down to the colon, which is the main food supply for colonocytes and so, keeps your colon healthy in that aspect too, as well. Now, seeds in higher, bulky items need to be taken with caution, if patients have any sort of stomach upset with ingestion to certain, common sense does apply, you should just avoid foods that create problems for you, and continue to take foods that promote your gut health in that aspect to, whether that be certain fibers, certain nuts or rice’s and grains, and such, and just to maintain that regimen throughout your life.

Melanie: So, it is important to identify those foods that might trigger some sort of an abdominal episode for people, so wrap it up for us, Dr. D, with your best advice about what you want people to know about diverticular disease, diverticulitis, and really what they can do to hopefully prevent it from happening in the first place.

Dr. Duldulao: Right, so when you do have these sorts of symptoms that are consistent with diverticular…diverticular disease or diverticulitis, it’s best sort of continue with a very healthy bowel regimen, including a high fiber diet, increased water intake, but also if the symptoms are persistent and they do bother you, they warrant evaluation with your primary care physician, having discussion with the gastroenterologist, and hopefully further questions do arise. Seeing a colorectal surgeon to discuss whether surgery is a valid option for you. In most cases, in patients with diverticular disease, it is a spectrum, and most cases are mild and can be managed medically and without any surgical intervention. However, when symptoms are bothersome and they are affecting the patient's quality of life, possibly surgery is what is warranted, but also the main message that should be taken is that, if you are starting to also have G.I. symptoms, especially if you feel that it's related to your colon or if you also have family history that dictates that you have a higher risk history for colorectal pathology, such as inflammatory bowel disease, ulcer colitis, colon erectile cancers, you should be evaluated and potentially get your colonoscopy sooner rather than later.

Melanie: And tell us about your team at Palmdale Regional Medical Center, why should they come there for their care?

Dr. Duldulao: So, our team at Palmdale Regional Medical Center is a multi-disciplinary team, although we are made up of primarily of colorectal surgeons. We do work well with the community including with the gastroenterologist locally, and with the primary care physician, to discuss ways to sort of treat complex and very difficult colon erectile pathology, and that is what we bring here at our specialty group, and we feel has been sort of under-served to the Antelope Valley community, and the main reason why people should choose us is that, we do like to discuss these complex issues with patients and help them understand how to take care of it, and we don't just involve ourselves, we're not a team that just wants to be captain of the ship. We're a team that want to feed a community of people and physicians and family together to help take care of the patient.

Melanie: Thank you so much, Dr. Duldulao, for being with us today. You're listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, you can go to PalmdaleRegional.com, that's PalmdaleRegional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole, thanks so much for listening.