What is the diagnosis and treatment for Diverticulosis (a condition characterized by the formation of diverticula in the digestive tract)?

From the Guidelines

Diverticulosis is a common condition that can be effectively managed with a high-fiber diet, hydration, and regular exercise, without the need for antibiotics in most cases, as supported by recent guidelines from the American College of Physicians 1. To manage diverticulosis, it is essential to focus on a high-fiber diet that includes fruits, vegetables, whole grains, and legumes, aiming for 25-35 grams of fiber daily. Gradually increasing fiber intake can help avoid gas and bloating. Staying well-hydrated by drinking at least 8 glasses of water daily can help soften stool, and regular exercise promotes healthy bowel function. If mild symptoms occur, over-the-counter fiber supplements like psyllium (Metamucil) or methylcellulose (Citrucel) can be helpful, starting with a low dose and increasing gradually. Avoiding non-steroidal anti-inflammatory drugs when possible is also recommended, as they may increase the risk of complications.

Some key points to consider in managing diverticulosis include:

• A high-fiber diet can help reduce the risk of complications by creating softer, bulkier stools that pass more easily through the colon, reducing pressure that can lead to pouch formation or complications.
• Antibiotics are not necessary for diverticulosis itself, but may be required if it progresses to diverticulitis (inflammation of the pouches), as indicated by recent evidence suggesting that antibiotics may be beneficial in certain cases, such as those with comorbidities or high-risk features 1.
• Regular monitoring and follow-up with a healthcare provider are essential to manage the condition effectively and prevent potential complications.
• Recent guidelines suggest that outpatient management may be suitable for most patients with acute uncomplicated diverticulitis, with selective use of antibiotics and imaging studies, as supported by low-certainty evidence 1.

It is crucial to note that while diverticulosis is generally a benign condition, it can progress to diverticulitis, which may require medical treatment with antibiotics. The decision to use antibiotics should be based on individual patient factors, such as the presence of comorbidities, high-risk features, or systemic inflammatory response, as recommended by recent guidelines 1.

From the Research

Definition and Prevalence of Diverticulosis

• Diverticulosis is a condition characterized by the presence of diverticula, which are mucosal outpouchings through the wall of the colon 2.
• The prevalence of diverticulosis increases with age, affecting over 5% of adults aged 40 years and older, with approximately 10-25% of affected individuals developing symptoms such as lower abdominal pain 2.

Treatment of Diverticulosis

• Treatment of patients with diverticulosis is generally based on a high-fibre diet, while treatment of diverticular disease (DD) is based on antibiotics, respectively 3.
• However, new pathophysiological knowledge suggests that further treatment may be useful, including the use of mesalazine, rifaximin, and probiotics 3, 4, 5, 6.
• The role of antibiotics in managing acute diverticulitis is questionable, particularly in patients with no complicating comorbidities, with two randomised controlled trials (RCTs) finding no significant benefit 3.
• Mesalazine has been shown to be effective in preventing acute diverticulitis in patients with symptomatic uncomplicated diverticular disease, with one RCT demonstrating a significant reduction in symptoms 3.
• Rifaximin and mesalazine have been found to be effective in treating symptomatic uncomplicated diverticular disease, with several RCTs demonstrating improved symptoms and reduced recurrence of diverticulitis 3, 4, 5.

Prevention of Diverticulitis

• The role of rifaximin or mesalazine in preventing diverticulitis recurrence is unclear, with conflicting evidence from RCTs 3, 4, 5.
• A systematic review found that treatment with fibre plus rifaximin resulted in a significant improvement in symptoms and a greater prevalence of symptom-free patients at 1 year, but the number needed to treat to prevent an attack of acute diverticulitis was high (57) 4.
• Mesalazine treatment has been shown to have some efficacy in preventing diverticulitis recurrence, but the evidence is conflicting, and further RCTs are needed to determine its effectiveness 5.
• The use of probiotics in diverticular disease and in preventing acute diverticulitis occurrence/recurrence appears promising but inconclusive, with some studies suggesting a potential benefit 3, 6.