What is the recommended management for diverticulosis?

Management of Diverticulosis

For asymptomatic diverticulosis, recommend a high-quality, fiber-rich diet (20-30 grams daily from fruits, vegetables, whole grains, and legumes), regular vigorous physical activity, maintaining normal body weight, smoking cessation, and avoiding NSAIDs when possible—no antibiotics, no routine imaging, and no dietary restrictions on nuts, seeds, or popcorn. 1, 2

Dietary Management

Primary Recommendation:

• Aim for >22.1 grams of fiber daily, as this threshold demonstrates statistically significant protective effects against progression to diverticulitis 1, 2
• Prioritize dietary fiber sources over supplements alone—fiber from fruits appears most protective compared to other sources 1, 2
• Gradually increase fiber intake to minimize abdominal bloating and improve tolerance 2
• A high-quality diet should be high in fiber from fruits, vegetables, whole grains, and legumes while low in red meat and sweets 1

Important Nuance: The evidence supporting fiber for diverticulosis is extrapolated from studies examining incident diverticulitis rather than recurrent disease, and the quality is very low 3. However, the 2015 AGA guidelines conditionally recommend fiber-rich diet or supplementation despite this limitation, as fiber poses minimal risk and aligns with general health recommendations 3. The 2025 Praxis guidelines strengthen this recommendation with specific thresholds based on more recent data 1, 2.

Lifestyle Modifications

• Engage in regular vigorous physical activity to decrease diverticulitis risk 3, 1, 2
• Achieve or maintain normal BMI, as obesity increases risk of progression 1, 2
• Avoid smoking, which is an established risk factor for diverticulitis 1, 2
• Minimize NSAID use when possible, as these medications are associated with increased diverticulitis risk 1, 2
• Aspirin use does not need to be routinely avoided 3, 1

What NOT to Do

Critical Pitfalls to Avoid:

• Do NOT restrict consumption of nuts, seeds, corn, or popcorn—this outdated recommendation lacks evidence and may actually reduce beneficial fiber intake 3, 1, 2
• Do NOT prescribe chronic antibiotics prophylactically—there is no role for routine antibiotic use in uncomplicated diverticulosis 1, 2
• Do NOT recommend mesalamine, rifaximin, or probiotics for prevention—the AGA strongly recommends against mesalamine and conditionally recommends against rifaximin and probiotics after acute uncomplicated diverticulitis 3
• Do NOT rely solely on fiber supplements instead of dietary modification 1, 2

Monitoring and Surveillance

• No routine imaging or colonoscopy is needed for asymptomatic diverticulosis 1, 2
• Recognize that approximately 50% of diverticulitis risk is attributable to genetic factors, so family history matters 1, 2
• Only 1-4% of patients with diverticulosis will develop acute diverticulitis in their lifetime 4

Patient Counseling Points

Explain to patients:

• The large majority of individuals with diverticulosis remain asymptomatic throughout their life 5, 6
• Approximately one-fifth may develop symptomatic diverticular disease, but only a minority will progress to acute diverticulitis 5
• Lifestyle modifications are the cornerstone of management—no medications are needed for asymptomatic disease 1, 2
• The old advice about avoiding nuts and seeds was based on theory rather than evidence and should be disregarded 3, 1, 2

When to Escalate Care

If diverticulosis progresses to uncomplicated diverticulitis:

• Initiate a clear liquid diet during the acute phase, advancing as symptoms improve 1
• For mild uncomplicated diverticulitis in immunocompetent patients, antibiotics can be used selectively rather than routinely 1
• Reserve antibiotics for patients with risk factors including immunocompromised status, comorbidities, frailty, refractory symptoms, vomiting, CRP >140 mg/L, WBC >15 × 10^9/L, or fluid collection/longer segment of inflammation on CT 1