Management of Diverticulosis
For asymptomatic diverticulosis, no medical treatment is required—focus exclusively on lifestyle modifications including a high-fiber diet (>22 grams daily from fruits, vegetables, whole grains, and legumes), regular vigorous physical activity, maintaining normal BMI, smoking cessation, and minimizing NSAID/opioid use when possible. 1
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
- Prioritize dietary fiber sources over supplements—fiber from fruits appears most protective compared to other sources. 1
- Gradually increase fiber intake to minimize abdominal bloating and improve tolerance. 1
- Fiber supplementation can be beneficial but should not replace a high-quality diet. 2
Critical pitfall to avoid: Do NOT restrict nuts, seeds, corn, or popcorn—this outdated recommendation lacks evidence and may actually reduce beneficial fiber intake. 2, 1
Lifestyle Modifications
- Physical activity: Engage in regular vigorous exercise to decrease diverticulitis risk. 2, 1
- Weight management: Achieve or maintain normal BMI, as obesity increases risk of progression. 2, 1
- Smoking cessation: Avoid smoking, which is an established risk factor for diverticulitis development. 2, 1
- Medication review: Minimize regular use of NSAIDs and opioids when possible, as these medications are associated with increased risk of diverticulitis. 2, 1
Monitoring and Surveillance
- No routine imaging or colonoscopy is needed for asymptomatic diverticulosis. 1
- Approximately 50% of diverticulitis risk is attributable to genetic factors, so family history matters in risk stratification. 2, 1
- Only 1-4% of patients with diverticulosis will develop acute diverticulitis in their lifetime. 3
What NOT to Do
- Do NOT prescribe chronic antibiotics prophylactically—there is no role for routine antibiotic use in uncomplicated diverticulosis. 2, 1
- Do NOT rely solely on fiber supplements instead of dietary modification. 1
- Do NOT recommend mesalamine or rifaximin for prevention in asymptomatic patients—these are not indicated. 2
When to Escalate Care
If diverticulosis progresses to symptomatic diverticular disease or acute diverticulitis, management changes dramatically:
- Clear liquid diet is advised during acute phase of uncomplicated diverticulitis, advancing as symptoms improve. 4, 2
- Selective antibiotic use (not routine) for uncomplicated diverticulitis in immunocompetent patients. 4, 2
- Antibiotics are mandatory for patients with: immunocompromised status, comorbidities/frailty, refractory symptoms, vomiting, CRP >140 mg/L, WBC >15 × 10⁹/L, or fluid collection/longer segment of inflammation on CT. 4, 2