Fistulas and Abscesses: Understanding Serious Diverticulitis Complications

Diverticulitis complications can transform a manageable condition into a serious medical emergency. Among the most concerning complications are fistulas and abscesses—complex problems that require immediate medical attention. As someone who has faced diverticulitis complications firsthand, I know how frightening and confusing these terms can be when first encountered in a doctor's office.

What Are Diverticular Abscesses?

An abscess is a pocket of infected fluid (pus) that forms when the inflammation from diverticulitis progresses to the point where the infected diverticulum ruptures or perforates. This allows bacteria from the colon to escape into surrounding tissues, creating a contained infection.

These pockets of infection can vary in size from less than a centimeter to several centimeters in diameter. They typically form around the affected segment of colon but can develop in various locations within the abdomen, including:

  • Pericolic: Directly adjacent to the colon wall
  • Pelvic: In the lower abdominal cavity
  • Intra-abdominal: Within the abdominal cavity but away from the colon
  • Retroperitoneal: Behind the peritoneum (the membrane lining the abdominal cavity)

According to a study published in the World Journal of Gastroenterology, abscesses occur in approximately 15-20% of patients hospitalized with acute diverticulitis.

Symptoms of Diverticular Abscesses

Abscesses often cause symptoms that are more severe than uncomplicated diverticulitis, including:

  • Intense, persistent abdominal pain (usually in the lower left abdomen)
  • High fever (often above 101°F/38.3°C)
  • Pronounced chills and sweating
  • Nausea and vomiting
  • Severe fatigue
  • Noticeable abdominal swelling or mass
  • Inability to pass gas or have bowel movements

If you experience these symptoms, especially after a known diverticulitis diagnosis, immediate medical evaluation is essential. Without proper treatment, abscesses can lead to peritonitis, a life-threatening condition requiring emergency surgery.

Understanding Diverticular Fistulas

A fistula is an abnormal connection or tunnel between two organs or between an organ and the skin. With diverticulitis, fistulas typically form when inflammation from a diverticulum erodes through the colon wall and into adjacent structures.

The development of a fistula represents the body's attempt to drain an abscess, but this "solution" creates a new set of problems. According to the Mayo Clinic, fistulas occur in approximately 14% of diverticulitis cases.

Types of Diverticular Fistulas

The location and connecting structures determine the type of fistula:

  1. Colovesical Fistula (most common)

    • Connection between colon and bladder
    • Symptoms: Urinary tract infections, air in urine (pneumaturia), fecal matter in urine, frequent urination
    • More common in men due to anatomical differences

  2. Colovaginal Fistula

    • Connection between colon and vagina
    • Symptoms: Passage of stool or gas from the vagina, foul-smelling vaginal discharge, recurrent vaginal infections
    • More common in women who've had hysterectomies

  3. Colocutaneous Fistula

    • Connection between colon and skin
    • Symptoms: Fecal drainage from an opening on the skin, skin irritation, infection

  4. Coloenteric Fistula

    • Connection between two parts of the intestine
    • Symptoms: Often asymptomatic, may cause diarrhea or malabsorption

  5. Colouterine Fistula (rare)

    • Connection between colon and uterus
    • Symptoms: Fecal matter passing through the uterus and vagina, pelvic pain, infections

My personal experience with a small pericolic abscess gave me firsthand knowledge of how quickly these complications can develop. What started as typical diverticulitis symptoms rapidly progressed to severe pain and high fever within 48 hours, necessitating hospitalization.

How Are These Complications Diagnosed?

Diagnosing abscesses and fistulas requires imaging studies. While your doctor may suspect these complications based on your symptoms and physical examination, confirmation typically requires:

  1. CT Scan with Contrast

    • The gold standard for diagnosing diverticulitis complications
    • Can clearly visualize abscesses and inflammatory changes
    • May show gas bubbles outside the bowel, indicating perforation

  2. MRI

    • Especially useful for evaluating fistulas
    • Provides detailed images of soft tissues without radiation exposure

  3. Contrast Studies

    • Barium enema or gastrografin studies can outline fistula tracts
    • Less commonly used now due to CT scan availability

  4. Cystoscopy/Colonoscopy

    • Direct visualization can confirm fistula openings
    • Often performed before surgical repair

For more information about diagnostic imaging for diverticulitis, check our detailed article on CT Scan vs Ultrasound vs MRI: Imaging Tests for Diverticulitis.

Treatment Options for Abscesses and Fistulas

Managing Diverticular Abscesses

Treatment depends on the size and location of the abscess:

Small Abscesses (<3cm)

  • Intravenous antibiotics (typically a combination that covers anaerobic and gram-negative bacteria)
  • Close monitoring with repeat imaging
  • Clear liquid diet progressing to low-residue diet as symptoms improve

Larger Abscesses (>3cm)

  • Percutaneous Drainage: A radiologist inserts a needle and catheter into the abscess under CT or ultrasound guidance to drain the infectious fluid
  • Continued antibiotic therapy
  • The drain typically remains in place until drainage decreases significantly
  • Success rates for this approach exceed 80%, according to the American Society of Colon and Rectal Surgeons

Failed Conservative Management

If antibiotics and drainage don't resolve the abscess, or if the patient's condition deteriorates, surgical intervention may be necessary:

  • Emergency Surgery: For severe cases with systemic infection
  • Staged Approach: Initial diversion with a colostomy followed by later resection and reversal

For a comprehensive overview of surgical options, read our article on Surgical Options for Diverticulitis: When Is It Necessary and What to Expect.

Managing Diverticular Fistulas

Fistulas almost always require surgical intervention, though the approach may vary:

Initial Management

  • Antibiotics to control infection
  • Nutritional support
  • Treatment of associated conditions (like urinary tract infections)

Definitive Treatment

  • Single-Stage Surgery: Removal of the diseased bowel segment and repair of the affected organ in one operation
  • Two-Stage Surgery: Creation of a temporary colostomy, followed by later reversal once inflammation resolves
  • Minimally Invasive Approaches: Laparoscopic or robotic techniques when appropriate

The specific surgical approach depends on:

  • Location and complexity of the fistula
  • Patient's overall health
  • Presence of active infection
  • Surgeon's expertise

According to a study in the Diseases of the Colon & Rectum journal, successful surgical management resolves fistulas in over 90% of cases, though recurrence is possible if diverticular disease persists.

Prevention and Long-Term Management

After recovering from an abscess or fistula, focus on preventing recurrent diverticulitis:

  1. Dietary Modifications

  2. Lifestyle Changes

    • Regular physical activity
    • Maintaining healthy weight
    • Stress management
    • Avoiding smoking

  3. Medical Follow-up

    • Colonoscopy after resolution (typically 6-8 weeks) to rule out other conditions
    • Regular check-ups with your gastroenterologist
    • Prompt attention to any recurring symptoms

For detailed guidance on preventing recurrence, see our article on Recurrent Diverticulitis: Why It Happens and How to Prevent It.

My Personal Journey with a Diverticular Abscess

When I developed an abscess during my second diverticulitis flare, the experience was markedly different from my first uncomplicated episode. The pain was more localized and intense, and my fever spiked to 103°F despite taking antibiotics.

The emergency CT scan revealed a 2.5cm pericolic abscess. I spent five days in the hospital receiving IV antibiotics and fluids. Fortunately, my abscess was small enough to resolve without drainage, but the experience taught me the importance of seeking medical attention promptly when symptoms escalate.

After recovery, my gastroenterologist emphasized the importance of maintaining long-term gut health to prevent future complications. This experience fundamentally changed how I approach my diverticular disease management, making me more proactive about tracking potential triggers and maintaining a fiber-rich diet.

When to Seek Emergency Care

If you have diverticulitis and develop any of these warning signs, seek immediate medical attention:

  • Severe, unrelenting abdominal pain
  • High fever (>101°F/38.3°C)
  • Inability to keep fluids down
  • Prolonged vomiting
  • No bowel movement for more than 3 days
  • Air or fecal matter in urine
  • Unusual drainage from vagina
  • Rigid, board-like abdomen
  • Dizziness, confusion, or extreme weakness

These symptoms could indicate a developing abscess, fistula, or peritonitis—all requiring prompt medical evaluation.

Conclusion

Abscesses and fistulas represent serious complications of diverticulitis that should never be ignored. With proper diagnosis and treatment, most patients recover successfully and can manage their diverticular disease effectively moving forward. Understanding these complications can help you recognize warning signs early and take appropriate action.

Living with diverticulitis means being vigilant about potential complications while not letting the condition control your life. By working closely with your healthcare team and implementing preventive strategies, you can minimize the risk of these serious complications and maintain your quality of life.

For a comprehensive understanding of all potential diverticulitis complications, read our overview article on Diverticulitis Complications: Prevention, Recognition, and Treatment.

Disclaimer: This article is based on personal experience and medical research but is not intended to replace professional medical advice. Always consult with your healthcare provider regarding any symptoms or treatment options for your specific situation.

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