What is the treatment for moderate colonic stool and diverticulosis (diverticulosis treatment)?

From the Guidelines

The treatment for moderate colonic stool and diverticulosis primarily involves dietary modifications, fiber supplementation, and adequate hydration, with a focus on preventing recurrence and managing symptoms. A high-fiber diet (25-35 grams daily) is recommended, including whole grains, fruits, vegetables, and legumes, as supported by the American College of Physicians guideline 1. Fiber supplements such as psyllium (Metamucil) at 1 teaspoon mixed in water 1-3 times daily, or methylcellulose (Citrucel) can be added if dietary fiber is insufficient. Drinking at least 8-10 glasses of water daily is essential to soften stool and prevent constipation. Regular physical activity helps promote normal bowel function. For occasional constipation, over-the-counter stool softeners like docusate sodium (100-300 mg daily) or osmotic laxatives such as polyethylene glycol (17 grams in water daily) may be used temporarily. Some key points to consider in the management of diverticulosis include:

• Avoiding seeds, nuts, and popcorn is no longer considered necessary as research hasn't shown they increase complications, as noted in the AGA clinical practice update 1.
• The use of mesalamine to prevent recurrent diverticulitis is not recommended, according to the American College of Physicians guideline 1.
• Elective surgery to prevent recurrent diverticulitis may be considered in patients with persistent or frequently recurring diverticulitis, after a discussion of potential benefits, harms, costs, and patient preferences, as suggested by the American College of Physicians guideline 1.
• A colonoscopy may be recommended after an initial episode of complicated left-sided colonic diverticulitis, especially if the patient has not had a recent colonoscopy, as recommended by the American College of Physicians guideline 1. These measures work by adding bulk to stool, promoting regular bowel movements, and reducing pressure in the colon that can lead to diverticular formation or complications of existing diverticula. If symptoms persist or worsen, medical evaluation is recommended as antibiotics may be needed for diverticulitis, as discussed in the AGA clinical practice update 1.

From the Research

Treatment for Moderate Colonic Stool and Diverticulosis

• The treatment for diverticulosis and diverticular disease is generally based on a high-fibre diet and antibiotics, respectively 2.
• A high-fibre diet appears to decrease the likelihood of symptomatic diverticulitis 3.
• The use of rifaximin, a poorly absorbed antibiotic, has been shown to be effective in soothing symptoms and preventing diverticulitis in patients with symptomatic uncomplicated diverticular disease 4, 5, 6.
• Rifaximin plus fibre supplementation has been found to be effective in obtaining symptom relief and preventing complications at 1 year in patients with symptomatic uncomplicated diverticular disease 4.
• Long-term efficacy of rifaximin has been demonstrated in managing symptomatic uncomplicated diverticular disease, with significant reduction in symptoms and risk of disease-related complications 6.

Medical Management

• Antibiotics have a role only in the treatment of complicated diverticulitis 2.
• Mesalazine has been found to be effective in preventing acute diverticulitis in patients with symptomatic uncomplicated diverticular disease 2.
• The role of probiotics in diverticular disease and in preventing acute diverticulitis occurrence/recurrence appears promising but inconclusive 2.

Surgical Management

• Surgical intervention appears to improve patient’s quality of life in cases of acute diverticulitis 3.
• The decision to proceed with surgery is recommended in an individualized manner, taking into account patient factors, disease severity, and surgeon preference and experience 3.
• Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment, although the operative approach may vary 3.