From the Guidelines
The gold standard for management of diverticulosis is a high-fiber diet, which should include 25-30 grams of fiber daily, as it focuses on prevention rather than treatment since diverticulosis itself is often asymptomatic. This approach is supported by the most recent evidence, including a 2021 clinical practice update on medical management of colonic diverticulitis, which emphasizes the importance of a high-quality diet in reducing the risk of recurrence and complications 1. Patients should gradually increase fiber intake through fruits, vegetables, whole grains, and legumes, or with fiber supplements such as psyllium (Metamucil), methylcellulose (Citrucel), or wheat dextrin (Benefiber) at doses of 3-6 grams daily.
Key Components of Management
- Adequate hydration with 6-8 glasses of water daily is essential to help the fiber work effectively.
- Physical activity should be encouraged as it promotes healthy bowel function.
- Patients should understand that genetic factors also contribute to diverticulitis risk, and that the risk of complicated diverticulitis is highest with the first presentation 1.
- A discussion of elective segmental resection for patients with a history of diverticulitis should be personalized to consider severity of disease, patient preferences and values, as well as risks and benefits, including quality of life 1.
Additional Considerations
- Antibiotic treatment can be used selectively, rather than routinely, in immunocompetent patients with mild acute uncomplicated diverticulitis 1.
- Patients with a history of complicated diverticulitis successfully managed without surgery are at increased risk of recurrence and complicated recurrence, and may benefit from elective resection 1.
- Chronically immunosuppressed patients should consult with a colorectal surgeon after recovery from an episode of acute diverticulitis successfully managed without surgery, as they are high risk for complicated recurrence 1.
From the Research
Management of Diverticulosis
The management of diverticulosis is a complex process that depends on various factors, including the presence of symptoms, the severity of the disease, and the patient's overall health.
- The gold standard for diagnosis is multi-detector CT, which has a sensitivity of 98% and specificity of up to 99% for diagnosing acute diverticulitis 2.
- For asymptomatic diverticulosis, fiber supplementation may prevent progression to symptomatic disease or improve symptoms in patients without inflammation 3.
- For symptomatic diverticulitis, the treatment approach depends on the severity of the disease and the presence of complications.
Treatment Approaches
- Uncomplicated diverticulitis may be safely managed as an outpatient in carefully selected patients, with antibiotics used selectively 4, 2.
- Complicated diverticulitis requires more aggressive treatment, including hospitalization, antibiotics, and possible surgical intervention 4, 2.
- Surgical intervention is indicated for disease that does not respond to medical management, repeated attacks, or complications such as abscess formation, fistula formation, obstruction, or free perforation 3, 2.
Role of Antibiotics
- The use of antibiotics in acute uncomplicated diverticulitis is controversial, with some studies suggesting that they may not be necessary 5.
- Antibiotics may be used selectively in patients with uncomplicated diverticulitis, but their use should be based on individual patient factors and disease severity 4, 2.
Surgical Management
- Surgical intervention is a key component of the management of diverticulitis, particularly for complicated cases 2, 6.
- The surgical approach depends on various factors, including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience 2.
- Laparoscopic lavage is a novel treatment modality that may be used in select patients with complicated diverticulitis 2, 6.