Management of diverticular disease

Main aim of treatment is to: (1)

• improving symptoms
• resolve any infection or consequences of inflammation
• prevent recurrence of symptoms
• prevent or limit the development of serious complications

Patients presenting with uncomplicated diverticular disease (nonspecific abdominal pain) can often be observed without any intervention.

• increasing dietary fibre and physical exercise may improve symptoms. In patients with a low-fibre diet and constipation, advise increasing fibre intake gradually to minimise flatulence and bloating, and advise adequate fluid consumption (2)
  
  
• NICE suggest general advice for managing diverticular disease (1):
  
  
  • do not offer antibiotics to people with diverticular disease
  • advise people to avoid non-steroidal anti-inflammatory drugs and opioid analgesia if possible, because they may increase the risk of diverticular perforation
  • advice on diet, fluid intake, stopping smoking, weight loss and exercise, then:
  • tell people with diverticulosis that the condition is asymptomatic and no specific treatments are needed.
  • advise people to eat a healthy, balanced diet including whole grains, fruit and vegetables. Tell them that:
    • there is no need to avoid seeds, nuts, popcorn or fruit skins
    • if they have constipation and a low-fibre diet, increasing their fibre intake gradually may minimise flatulence and bloating
  • advise people to drink adequate fluid if they are increasing their fibre intake, especially if there is a risk of dehydration.
  • consider bulk-forming laxatives for people with constipation.
  • tell people about the benefits of exercise, and weight loss if they are overweight or obese, and stopping smoking, in reducing the risk of developing acute diverticulitis and symptomatic disease
  • advise people that:
  • the benefits of increasing dietary fibre may take several weeks to achieve
  • if tolerated, a high-fibre diet should be maintained for life
  • consider bulk-forming laxatives if:
  • a high-fibre diet is unacceptable to the person or it is not tolerated or
  • the person has persistent constipation or diarrhoea
  • consider simple analgesia, for example paracetamol, as needed if the person has ongoing abdominal pain
  • consider an antispasmodic if the person has abdominal cramping
  • if the person has persistent symptoms or symptoms that do not respond to treatment, think about alternative causes and investigate and manage
    appropriately

Diverticulitis

• diverticulitis without any significant complications (1)
  • generally treated with bed rest, IV fluids, analgesics, IV antibiotics - for example cefuroxime and metronidazole - and antispasmodics
  • surgical intervention is only required in the minority of cases.
  • in some instances, patients with mild symptoms (in the absence of signs of systemic toxicity) can be treated in the community in the first instance and referred to specialist care if appropriate (1)
    • outpatients should be treated with a clear liquid diet and a broad-spectrum oral antibiotic regime with activity against anaerobes and gram-negative rods (1)
    • common outpatient regimens for suspected or confirmed uncomplicated acute diverticulitis is typically a 5-day course of the following oral antibiotics (1):
    • Amoxicillin/clavulanate as the first-line choice
    • Or, if amoxicillin/clavulanate is unsuitable or the patient has a penicillin allergy: Cefalexin (use caution in patients with a penicillin allergy) plus metronidazole; or Trimethoprim plus metronidazole; or
    • Ciprofloxacin (only if switching from intravenous ciprofloxacin with specialist advice) plus metronidazole. .
      • the goal of antibiotic therapy is to reduce diverticular complications and risk of recurrence
      • some European studies have reported that in mild to even moderate uncomplicated disease, antibiotics may not be necessary
        • in fact, American Gastroenterological Association (AGA) guidelines recommends selective use of antibiotics as opposed to routine use in patients with uncomplicated diverticulitis (3)
  • clinical improvement is usually seen within 2-3 days
  • if patient is unsuitable for outpatient treatment or fails to improve with outpatient therapy, hospitalisation with IV antibiotics treatment should be considered
• complicated diverticulitis (1)
  • patients may present with abscess, peritonitis, fistula formation or obstruction
  • patients should be hospitalised and treated with IV antibiotics, bowel rest and surgical consultation

Possible indications for surgery include:

• purulent or faecal peritonitis
• uncontrolled sepsis
• fistula
• obstruction
• inability to exclude carcinoma

Chronic diverticular disease is treated with a high fibre diet, antispasmodics and laxatives, e.g. ispaghula husk, nocte, lactulose 10-20 ml bd.

Notes:

• use of non-steroidal anti-inflammatory drugs is the most consistently identified risk factor for diverticular perforation but accounts for only a fifth of all cases of perforation (4)
  • hypothesised mechanism is due to the adverse affect of prostaglandin inhibition on mucosal blood flow
  • thus if considering the use of non-steroidal anti-inflammatory drugs for patients with diverticular disease, the risk of perforation should be balanced against the therapeutic benefit

Reference:

1. Diverticular disease: diagnosis and management. NICE Guidance NG47. (November 2019)
2. Ma W, Nguyen LH, Song M, et al. Intake of dietary fiber, fruits, and vegetables and risk of diverticulitis. Am J Gastroenterol. 2019 Sep;114(9):1531-8.
3. Feuerstein JD, Falchuk KR. Diverticulosis and Diverticulitis. Mayo Clin Proc. 2016 Aug;91(8):1094-104
4. Janes SE et al. Management of diverticulitis. BMJ 2006;332:271-5.