Management of Uncomplicated Diverticulosis
For patients with asymptomatic or minimally symptomatic diverticulosis, lifestyle modification with a high-fiber diet is the cornerstone of management, with no role for routine antibiotics or other pharmacologic interventions. 1
Dietary Management
Recommend a high-quality diet containing ≥22 g/day of fiber from fruits, vegetables, whole grains, and legumes, while minimizing red meat and sweets. This is the single most evidence-based intervention to prevent progression from diverticulosis to diverticulitis. 1
Fiber supplementation (e.g., psyllium, methylcellulose) can be offered as an adjunct but should not replace dietary fiber. Supplementation alone is insufficient; whole-food sources provide additional protective benefits. 1
Explicitly counsel patients that nuts, corn, popcorn, and small-seeded fruits do NOT increase diverticulitis risk and should not be restricted. This is a high-quality recommendation that contradicts outdated dietary advice. 1
Lifestyle Modifications
Advise regular vigorous physical activity to reduce the risk of progression to acute diverticulitis. 1
Encourage achieving or maintaining a normal BMI (18–25 kg/m²) as obesity is a modifiable risk factor for diverticulitis. 1
Strongly recommend smoking cessation, as tobacco use increases diverticulitis risk. 1
Minimize use of NSAIDs and opioids when possible, as both medication classes are associated with increased risk of diverticulitis and its complications. 1
What NOT to Do
Do not prescribe antibiotics (including rifaximin), mesalamine, or probiotics for asymptomatic diverticulosis. There is no evidence these agents prevent progression to diverticulitis, and mesalamine carries a strong recommendation against its use for this indication. 1
Do not perform routine colonoscopy solely because diverticula are present on imaging. Colonoscopy is reserved for age-appropriate colorectal cancer screening or if alarm features (rectal bleeding, iron-deficiency anemia, weight loss, change in stool caliber) are present. 1
Do not recommend restrictive diets (avoiding seeds, nuts, popcorn), as this outdated practice reduces overall fiber intake without any proven benefit. 1
When to Escalate Care
If the patient develops left lower quadrant pain, fever, or change in bowel habits, obtain a contrast-enhanced CT scan to evaluate for acute diverticulitis rather than assuming uncomplicated disease. 1, 2
Approximately 1–4% of patients with diverticulosis will develop acute diverticulitis in their lifetime, so patient education about warning signs (persistent abdominal pain, fever >100.4°F, inability to tolerate oral intake) is essential. 3
Special Populations
Patients with genetic risk factors (e.g., TNFSF15 gene variants, connective tissue disorders such as Marfan syndrome, Ehlers-Danlos syndrome, or polycystic kidney disease) warrant more aggressive lifestyle counseling, as they have higher baseline risk of diverticular complications. 3
Patients on chronic corticosteroids or immunosuppression require lower thresholds for imaging and specialist referral if any symptoms develop, as they are at higher risk for perforation and complicated disease. 1
Common Pitfalls
Prescribing rifaximin or mesalamine "to prevent flares" is not supported by evidence and adds unnecessary cost and potential adverse effects. 1
Assuming fiber worsens symptoms during an acute flare: Fiber should be temporarily reduced during acute diverticulitis but resumed once symptoms resolve to prevent recurrence. 1
Failing to distinguish diverticulosis (asymptomatic) from diverticulitis (acute inflammation): The former requires only lifestyle measures, while the latter may require antibiotics and imaging. 1, 2