What is the management of colonic diverticulosis?

Management of Colonic Diverticulosis

The management of colonic diverticulosis should focus on dietary and lifestyle modifications, including a high-fiber diet (25-35g daily), regular physical activity, maintaining normal BMI, and avoiding smoking, as these measures can reduce the risk of progression to symptomatic diverticular disease. 1, 2

Understanding Diverticulosis

Diverticulosis refers to the presence of diverticula (outpouchings of the intestinal wall) in the colon. Important facts to understand:

• Approximately 50% of people over age 60 and 60% over age 80 have colonic diverticula 3
• Most individuals with diverticulosis remain asymptomatic
• About 25% will develop symptomatic diverticular disease 4
• Approximately 50% of diverticulitis risk is attributable to genetic factors 1

Dietary Recommendations

• High-fiber diet (25-35g daily) from:

  • Fruits
  • Vegetables
  • Whole grains
  • Legumes
  • Low in red meat and sweets 1

• Fiber supplements:

  • Psyllium fiber (15g daily) can augment dietary fiber intake 2
  • Note: Fiber supplements are not a replacement for a high-quality diet 1

• Foods that do NOT need to be avoided:

  • Nuts, corn, and popcorn (contrary to old beliefs) 1, 5
  • Fruits with small seeds (strawberries, blueberries) 1

Lifestyle Modifications

• Physical activity:

  • Regular vigorous exercise decreases risk 1, 2

• Weight management:

  • Maintain normal body mass index (BMI) 1, 2
  • Obesity, particularly central obesity, increases risk 1

• Avoid smoking:

  • Smoking is a risk factor for diverticular disease 1, 2

• Alcohol consumption:

  • Alcoholism (not moderate alcohol consumption) increases risk 1

Medication Considerations

• Avoid regular use of NSAIDs:

  • Increases risk of diverticulitis 1, 2
  • Risk is greater for non-aspirin NSAIDs than for aspirin 1

• Aspirin considerations:

  • Has slightly increased risk of diverticulitis (RR 1.25)
  • Should not be discontinued if prescribed for cardiovascular protection 2

• Avoid opioid analgesics:

  • Associated with diverticulitis and perforation 1, 2

• Avoid corticosteroids when possible:

  • Associated with diverticulitis and perforation 1

Preventive Medications

• Not recommended for prevention:
  • 5-aminosalicylic acid
  • Probiotics
  • Rifaximin 1

Monitoring and Follow-up

• Colonoscopy:

  • Recommended 6-8 weeks after resolution of acute symptoms if not performed within the past year 2
  • Earlier if alarm symptoms are present 2

• Laboratory tests:

  • Complete blood count
  • C-reactive protein (CRP) levels
  • Procalcitonin (to rule out ongoing inflammation) 2

Management of Complications

If Diverticulitis Develops:

• Uncomplicated diverticulitis:

  • Selective use of antibiotics in immunocompetent patients 1, 2
  • Clear liquid diet during acute phase, advancing to regular diet within 3-5 days 2
  • Acetaminophen as first-line analgesic 2

• For immunocompromised patients:

  • Low threshold for imaging, antibiotic treatment, and surgical consultation 1
  • Antibiotic regimen with gram-negative and anaerobic coverage 1

Important Caveat

Patients should be educated that complicated diverticulitis is most often the first presentation of diverticulitis, not a progression from uncomplicated disease. The risk of complicated diverticulitis actually decreases with recurrences 1.

Constipation Management

• First-line treatment:

  • Osmotic laxatives (polyethylene glycol 17g daily or milk of magnesia 1 oz twice daily) 2

• Second-line treatment:

  • Stimulant laxatives (bisacodyl or glycerol suppositories) if inadequate response to first-line 2

By following these management strategies, patients with colonic diverticulosis can reduce their risk of developing symptomatic diverticular disease and improve their overall quality of life.