Progress and challenges in the management of diverticular disease: which treatment?

Abstract

Diverticular disease of the colon (DDC) includes a spectrum of conditions from asymptomatic diverticulosis to symptomatic uncomplicated diverticulosis, segmental colitis associated with diverticulosis, and acute diverticulitis without or with complications that may have serious consequences. Clinical and scientific interest in DDC is increasing because of the rising incidence of all conditions within the DDC spectrum, a better, although still limited understanding of the pathogenic mechanisms involved; the increasing socioeconomic burden; and the new therapeutic options being tested. The goals of treatment in DDC are symptom and inflammation relief and preventing disease progression or recurrence. The basis for preventing disease progression remains a high-fiber diet and physical exercise, although evidence is poor. Other current strategies do not meet expectations or lack a solid mechanistic foundation; these strategies include modulation of gut microbiota or dysbiosis with rifaximin or probiotics, or using mesalazine for low-grade inflammation in uncomplicated symptomatic diverticulosis. Most acute diverticulitis is uncomplicated, and the trend is to avoid hospitalization and unnecessary antibiotic therapy, but patients with comorbidities, sepsis, or immunodeficiency should receive broad spectrum and appropriate antibiotics. Complicated acute diverticulitis may require interventional radiology or surgery, although the best surgical approach (open versus laparoscopic) remains a matter of discussion. Prevention of acute diverticulitis recurrence remains undefined, as do therapeutic strategies. Mesalazine with or without probiotics has failed to prevent diverticulitis recurrence, whereas new studies are needed to validate preliminary positive results with rifaximin. Surgery is another option, but the number of acute events cannot guide this indication. We need to identify risk factors and disease progression or recurrence mechanisms to implement appropriate preventive strategies.

Keywords: antibiotics; diverticular disease; diverticulitis; fiber; mesalazine; probiotics; rifaximin; treatment.

Figure 1.

Graphical expression of relative risks (RRs) and 95% confidence of intervals (CIs) of sociodemographic determinants of hospital admissions for diverticular disease adjusted for the year of birth and sex. Reference for ethnicity was native Swedish people. The figure depicts 10-year risk of hospitalization due to diverticular disease observed in a cohort of 4 million residents in Sweden. It shows lower risk in nonwestern immigrants compared with native Swedish people. Determinants other than ethnicity can be found in the study by Herne and colleagues and include type of work, recipient of social welfare, type of housing and urban residency.

Figure 2.

Risk of hospital admission or death due to diverticular disease associated with diet habits in a cohort of 47,033 men and women living in England and Scotland. In relative terms, that risk was 31% lower for vegetarian or vegan patients compared with meat eaters. The risk was 41% lower for those patients taking fiber in the highest fifth quintile.. CI, confidence interval; RR, relative risk.

Figure 3.

Algorithm defining current therapeutic strategies for symptomatic uncomplicated diverticular disease (SUDD). Evidence is very poor, supporting the use of fiber or spasmolitics. Evidence is also limited for the use of other compounds, but rifaximin has been shown to reduce symptoms and reduces the risk of development of acute diverticulitis, whereas mesalazine use is controversial, since it was found not to relive symptoms or prevent acute diverticulitis in some studies, although a recent meta-analysis shows that it can be effective for both outcomes.^–,

Figure 4.

Algorithm defining current therapeutic strategies for acute diverticulitis. See the appropriate section in text.