Management of colonic diverticular disease with poorly absorbed antibiotics and other therapies

Abstract

Colonic diverticular disease is common in Western countries and its prevalence increases with age. The large majority of patients (80-85%) will remain entirely asymptomatic throughout their life. In symptomatic cases, most patients will have diverticulosis without inflammation while the remainder will have diverticulitis with or without complications. About 1-2% will require hospitalization and 0.5% will require surgery. Factors predicting the development of symptoms remain to be identified. However, it is generally recognized that diverticular disease is probably related to complex interactions between colon structure, intestinal motility, diet, and genetic features. Epidemiologic studies have demonstrated an association between diverticulosis and diets that are low in fiber and high in refined carbohydrates. Although the causes of symptom development are still unclear, it is thought that previous episodes of intestinal inflammation may play a role. Changes in intestinal microflora could be one of the putative mechanisms responsible for low-grade inflammation. In patients with uncomplicated diverticulosis, a diet abundant in fruit and vegetables is recommended. The current therapeutic approaches in preventing recurrence of symptoms are based on nonabsorbable antibiotics, mesalazine, and/or probiotics. Cyclic rifaximin administration seems to be an adequate approach to relieving symptoms and preventing acute diverticulitis in patients with symptomatic diverticulosis.

Keywords: diverticular disease of the colon; diverticulitis; diverticulosis; mesalazine; probiotics; rifaximin.

Figure 1.

The majority of patients harboring colonic diverticula remain asymptomatic throughout their life (asymptomatic diverticular disease); only 20% will develop symptoms and signs of illness. Symptomatic diverticular disease is further subdivided into painful diverticular disease (symptomatic diverticular disease with no inflammation) and diverticulitis (symptomatic diverticular disease with inflammation). Diverticulitis is further subdivided into uncomplicated and complicated diverticulitis. DD, diverticular disease.

Figure 2.

Diverticular disease: putative role of intestinal bacterial overgrowth in symptom development. Altered intestinal microflora could contribute to chronic low-grade inflammation which abnormally sensitized both intrinsic primary efferent and extrinsic primary afferent neurons. This condition could lead to neural and muscle dysfunction and, finally, to symptom development. (Adapted from Colecchia et al. [2003].)

Figure 3.

Antibiotics decrease intraluminal pressure in patients with diverticular disease. SIBO, small intestinal bacterial overgrowth. (Adapted from Frieri et al. [2006].)