Understanding and Managing Uncomplicated Diverticulosis
What is Diverticulosis?
Diverticulosis is defined by the presence of multiple outpouchings (diverticula) originating from the intestinal lumen, and it is a common condition affecting up to 50% of people by age 80. 1, 2
- Diverticulosis itself is asymptomatic and represents the structural presence of diverticula without inflammation 1
- Only 1-4% of patients with diverticulosis will develop acute diverticulitis (inflammation of the diverticula) in their lifetime 1
- Risk factors include age >65 years, genetic variants, obesity (BMI ≥30), use of opioids/steroids/NSAIDs, hypertension, and type 2 diabetes 1
Management of Uncomplicated Diverticulosis
For older patients with uncomplicated diverticulosis (no inflammation or symptoms), no pharmacological treatment is required—management focuses entirely on lifestyle modifications to prevent progression to diverticulitis. 3, 4
Dietary Recommendations
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. 3, 5
- The protective effect of dietary fiber becomes statistically significant at intakes exceeding 22.1 g/day 3
- Fiber from fruits appears to have the strongest protective association 3
- Fiber supplementation can be beneficial but should not replace a high-quality diet 3
Contrary to popular belief, patients should NOT restrict consumption of nuts, corn, popcorn, or small-seeded fruits—these foods are not associated with increased risk of diverticulitis. 3, 6
Lifestyle Modifications
Regular vigorous physical activity is strongly recommended to decrease the risk of progression to diverticulitis. 3, 6
Achieve or maintain a normal body mass index (18-25 kg/m²). 3
Smoking cessation is essential, as smoking is a risk factor for diverticulitis. 3
Avoid chronic use of NSAIDs (except aspirin prescribed for cardiovascular disease prevention) and opioids, as these medications increase the risk of diverticulitis. 7, 3
Important Genetic Considerations
Patients should understand that approximately 50% of diverticulitis risk is attributable to genetic factors, meaning that even with optimal lifestyle modifications, some risk remains. 7, 3
Common Pitfalls to Avoid
Do not prescribe mesalamine or rifaximin for prevention of diverticulitis in patients with diverticulosis—these medications have no proven benefit and may cause adverse events. 3
Do not unnecessarily restrict dietary intake of nuts, seeds, or popcorn, as this outdated advice is not evidence-based and may reduce overall fiber intake. 3
Do not prescribe antibiotics for asymptomatic diverticulosis—antibiotics are only indicated if the patient develops acute diverticulitis with specific risk factors. 3
When to Escalate Care
If a patient with diverticulosis develops left lower quadrant pain, fever, nausea, vomiting, or elevated white blood cell count, they may have progressed to acute diverticulitis and require CT imaging for diagnosis. 1, 8