How do you treat colonic diverticulosis?

Treatment of Colonic Diverticulosis

Asymptomatic colonic diverticulosis does not require medical treatment—only lifestyle modifications including a high-fiber diet, regular physical activity, maintaining normal BMI, and smoking cessation are recommended. 1

Key Distinction: Diverticulosis vs. Diverticulitis

The question asks about diverticulosis (the presence of diverticula without inflammation), not diverticulitis (acute inflammation). This is a critical distinction that fundamentally changes management:

• Diverticulosis is asymptomatic in 80-85% of patients and requires no active medical treatment 2
• Only 1-4% of patients with diverticulosis will ever develop acute diverticulitis in their lifetime 3
• The goal in diverticulosis is prevention of progression to diverticulitis, not treatment of active disease 4

Recommended Management for Diverticulosis

Dietary Modifications

• Consume a high-quality, fiber-rich diet with high intake of fruits, vegetables, whole grains, and legumes, while limiting red meat and sweets 1, 5
• Target fiber intake >22.1 g/day, as this threshold shows statistically significant protective effects against diverticular disease progression 5
• Fiber supplementation (such as glucomannan) can be used but should not replace a high-quality diet 5, 6
• Do NOT restrict nuts, corn, popcorn, or small-seeded fruits—these are not associated with increased risk of diverticulitis and this outdated advice may actually reduce beneficial fiber intake 1, 5

Lifestyle Modifications

• Engage in regular vigorous physical activity to decrease risk of diverticulitis 5
• Achieve or maintain normal body mass index (BMI <30) 1, 5
• Avoid smoking, as it is a significant risk factor for diverticulitis 1, 5
• Avoid regular NSAID use (except aspirin for cardiovascular secondary prevention) 5

Patient Education

• Counsel patients that approximately 50% of diverticulitis risk is attributable to genetic factors that cannot be modified 1, 5
• Explain that most people with diverticulosis remain asymptomatic throughout their lives 2
• Emphasize that lifestyle modifications are aimed at reducing the small risk of progression to diverticulitis 4

What NOT to Do

No Routine Antibiotics

• Antibiotics have no role in asymptomatic diverticulosis 1
• Cyclic rifaximin has been studied for symptomatic uncomplicated diverticulosis but is not indicated for asymptomatic disease 6, 2

No Routine Medications

• Mesalazine has been studied for symptomatic diverticulosis but has no role in asymptomatic disease 4, 2
• Probiotics lack solid evidence for preventing disease progression in asymptomatic diverticulosis 4

No Routine Surveillance

• Colonoscopy is not indicated solely for the presence of diverticulosis unless there are other screening indications 1

Common Pitfalls to Avoid

• Confusing diverticulosis with diverticulitis: Diverticulosis is the anatomic presence of diverticula; diverticulitis is acute inflammation requiring different management 3
• Prescribing unnecessary antibiotics: This contributes to antibiotic resistance without clinical benefit in asymptomatic patients 5
• Recommending overly restrictive diets: Avoiding nuts, seeds, and popcorn is not evidence-based and may reduce overall fiber intake 1, 5
• Failing to address modifiable risk factors: Weight reduction and smoking cessation are evidence-based interventions that patients can control 1

When to Escalate Care

If a patient with known diverticulosis develops left lower quadrant pain, fever, nausea, vomiting, or leukocytosis, they may have progressed to acute diverticulitis and require CT imaging and different management strategies 3. At that point, the treatment paradigm shifts entirely to managing acute inflammation rather than asymptomatic diverticulosis.