What management and treatment options are recommended for a patient with diverticulosis (a condition where small, bulging pouches develop in the digestive tract) without diverticulitis (inflammation of these pouches), prominent stool in the colon, and no other acute abdominal or pelvic processes, as shown on a computed tomography (CT) scan of the abdomen?

Management of Diverticulosis Without Diverticulitis

For a patient with CT-confirmed diverticulosis without diverticulitis and prominent stool, no treatment is required for the diverticulosis itself—focus on addressing the constipation and implementing lifestyle modifications to prevent future progression to diverticulitis. 1

Immediate Management: Address the Constipation

• Use polyethylene glycol (MiraLAX) as the preferred agent for managing the prominent stool burden, ensuring adequate hydration to prevent complications 2
• Avoid fiber supplementation during acute constipation until the stool burden is cleared, as adding fiber to an already impacted colon can worsen symptoms 3
• Once the constipation resolves, gradually introduce a high-fiber diet to prevent recurrence 1

Long-Term Prevention Strategy: Reduce Risk of Progression to Diverticulitis

Dietary Modifications

• Adopt a high-quality diet rich in fiber (>22.1 g/day) from fruits, vegetables, whole grains, and legumes, while limiting red meat and sweets 1, 2
• The protective effect of dietary fiber becomes statistically significant at intakes exceeding 22.1 g/day 1
• Do NOT restrict consumption of nuts, corn, popcorn, or small-seeded fruits—these foods are not associated with increased risk of diverticulitis and may actually have a protective effect 1, 4
• Fiber supplementation can be beneficial but should not replace a high-quality diet 1

Lifestyle Modifications

• Engage in regular vigorous physical activity to decrease the risk of diverticulitis 1, 2
• Achieve or maintain a normal body mass index (BMI 18-25 kg/m²) 1, 2
• Avoid smoking, as it is a significant risk factor for diverticulitis 1, 2
• Minimize use of NSAIDs and opioids when possible, as these medications are associated with increased risk of diverticulitis 1, 5

What NOT to Do

• Do not prescribe antibiotics—diverticulosis without inflammation does not require antibiotic treatment 1
• Do not prescribe mesalamine or rifaximin for prevention, as high-certainty evidence shows no benefit in preventing diverticulitis 1
• Do not recommend colonoscopy unless the patient is >50 years old and due for routine colorectal cancer screening, or has other concerning symptoms like rectal bleeding 1, 5
• Do not advise a low-residue or restrictive diet—this outdated recommendation should be abandoned 6

Follow-Up Considerations

• No routine follow-up imaging is needed for asymptomatic diverticulosis 1
• Educate the patient on warning signs of diverticulitis: left lower quadrant pain, fever, nausea, vomiting, or change in bowel habits persisting beyond resolution of current constipation 5
• If the patient develops symptoms concerning for diverticulitis in the future, they should seek medical attention for potential CT imaging and risk stratification 1

Key Clinical Pearls

• Approximately 50% of people over age 60 have diverticulosis, but only 1-4% will develop acute diverticulitis in their lifetime 5, 7
• The prominent stool seen on CT is a separate issue from the diverticulosis and should be managed as simple constipation 2
• Genetic factors account for approximately 50% of diverticulitis risk, so lifestyle modifications can only partially mitigate risk 1