What is the management and treatment of diverticulosis?

Management and Treatment of Diverticulosis

For patients with diverticulosis, a fiber-rich diet or fiber supplementation is recommended to reduce the risk of progression to diverticulitis. 1

Understanding Diverticulosis

• Diverticulosis is an anatomical condition characterized by outpouchings (diverticula) in the colon wall, affecting up to 71.4% of people over age 80 2
• Only about 4-5% of people with diverticulosis will develop diverticulitis in their lifetime 2, 3
• Approximately 50% of the risk for diverticulitis is attributable to genetic factors 1

Dietary Management for Diverticulosis

• A high-quality diet that is high in fiber from fruits, vegetables, whole grains, and legumes and low in red meat and sweets is recommended 1, 4
• Fiber supplementation can be beneficial but is not a replacement for a high-quality diet 1, 4
• Contrary to popular belief, consumption of nuts, corn, popcorn, and small-seeded fruits is not associated with increased risk of diverticulitis 1, 5
• Higher consumption of red meat is associated with a mild increase in risk of acute diverticulitis 5
• Higher fish intake may be associated with reduced risk of diverticulitis 5

Lifestyle Modifications

• Regular physical activity, particularly vigorous exercise, is recommended to decrease risk 1
• Achieving or maintaining a normal body mass index is important 1, 4
• Avoiding smoking is advised as it is a risk factor for diverticulitis 1, 4
• Limiting alcohol consumption is recommended, as high alcohol intake has a mild association with diverticulosis 5

Medication Considerations

• Avoid regular use of NSAIDs when possible, as they increase risk of diverticulitis 4, 6
• Opioid analgesics and corticosteroids are also associated with increased risk of diverticulitis 4, 6

Management of Symptomatic Diverticulosis

• For symptomatic diverticulosis without inflammation, a combination of soluble fiber (like glucomannan) and poorly absorbed antibiotics (like rifaximin) given 7-10 days every month may provide symptom relief 7
• Low to modest doses of tricyclic antidepressants may be considered for chronic abdominal pain after diverticulitis with no evidence of inflammation 4

Management of Acute Diverticulitis

• For uncomplicated diverticulitis in immunocompetent patients, observation with pain management (typically acetaminophen) and a clear liquid diet is recommended 4, 3

• Antibiotics should be reserved for patients with:

  • Systemic symptoms (persistent fever, chills)
  • Increasing leukocytosis
  • Age >80 years
  • Pregnancy
  • Immunocompromised status
  • Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 4, 3

• When antibiotics are necessary for uncomplicated diverticulitis:

  • Outpatient: Oral amoxicillin-clavulanate or ciprofloxacin plus metronidazole for 4-7 days 4, 3
  • Inpatient: IV antibiotics with gram-negative and anaerobic coverage 4

• For complicated diverticulitis (abscess, perforation, fistula, stricture):

  • IV antibiotics such as piperacillin/tazobactam 4g/0.5g q6h or eravacycline 1mg/kg q12h for critically ill or immunocompromised patients 1, 8
  • Duration: 4 days for immunocompetent patients with adequate source control; up to 7 days for immunocompromised or critically ill patients 1, 8

Prevention of Recurrence

• Continuous fiber intake and intermittent courses of rifaximin may improve symptoms and reduce diverticulitis recurrence 7
• Surgical intervention may be indicated after multiple episodes of diverticulitis, particularly in younger patients and immunocompromised patients 7, 6

Common Pitfalls to Avoid

• Overuse of antibiotics in uncomplicated cases without risk factors 4
• Restricting consumption of nuts, corn, popcorn, or small-seeded fruits unnecessarily 1, 4
• Using fiber supplements as a replacement for a high-quality diet 4
• Assuming abdominal distension is directly caused by diverticulosis rather than considering other potential causes 2