Symptomatic Uncomplicated Diverticular Disease (SUDD): Practical Guidance and Challenges for Clinical Management

Abstract

Symptomatic Uncomplicated Diverticular Disease (SUDD) is a syndrome within the diverticular disease spectrum, characterized by local abdominal pain with bowel movement changes but without systemic inflammation. This narrative review reports current knowledge, delivers practical guidance, and reveals challenges for the clinical management of SUDD. A broad and common consensus on the definition of SUDD is still needed. However, it is mainly considered a chronic condition that impairs quality of life (QoL) and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (eg, diarrhea) and low-grade inflammation (eg, elevated calprotectin) but without systemic inflammation. Age, genetic predisposition, obesity, physical inactivity, low-fiber diet, and smoking are considered risk factors. The pathogenesis of SUDD is not entirely clarified. It seems to result from an interaction between fecal microbiota alterations, neuro-immune enteric interactions, and muscular system dysfunction associated with a low-grade and local inflammatory state. At diagnosis, it is essential to assess baseline clinical and Quality of Life (QoL) scores to evaluate treatment efficacy and, ideally, to enroll patients in cohort studies, clinical trials, or registries. SUDD treatments aim to improve symptoms and QoL, prevent recurrence, and avoid disease progression and complications. An overall healthy lifestyle - physical activity and a high-fiber diet, with a focus on whole grains, fruits, and vegetables - is encouraged. Probiotics could effectively reduce symptoms in patients with SUDD, but their utility is missing adequate evidence. Using Rifaximin plus fiber and Mesalazine offers potential in controlling symptoms in patients with SUDD and might prevent acute diverticulitis. Surgery could be considered in patients with medical treatment failure and persistently impaired QoL. Still, studies with well-defined diagnostic criteria for SUDD that evaluate the safety, QoL, effectiveness, and cost-effectiveness of these interventions using standard scores and comparable outcomes are needed.

Keywords: colonic diverticulosis; diverticulitis; irritable bowel syndrome; microbiota; probiotic; treatment.

Figure 1

Diagnosis of SUDD. SUDD is mainly considered a chronic condition that impairs quality of life and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (diarrhea, constipation, and bloating) and local inflammation (elevated calprotectin and at pathology) but without systemic inflammation. Figure created with BioRender.com.

Figure 2

Management of patients with SUDD. SUDD management aims to improve symptoms and QoL, prevent a recurrence, and avoid diverticulitis and complications. Therefore, it is pivotal to determine QoL (DV-QOL) and clinical scores (DCIS) at baseline and enroll patients in cohort studies, clinical trials, or registries to ensure an adequate follow-up and fill the knowledge gap. Treatments: cyclic Rifaximin (400 mg/12 h) 7 days/month plus High-fiber diet ± supplemental fiber to reduce symptoms and improve remission [EL: 2b; RG: B]; Mesalazine 800 mg/12 h to enhance remission [EL: 1b; RG: A]; low-grade evidence for probiotics [EL: 3a; RG: B]; surgery in chronic persistent SUDD with low QoL [EL 3; RG C]; no evidence for nutraceutical formulation, anticholinergic or antispasmodic drug. Evidence Level (EL) and Recommendation Grade (RG) are reported according to OCEBM. DV-QOL is a specific diverticular disease QoL instrument for patients with SUDD., DCIS is a diverticular clinical score developed and validated for patients with SUDD. Figure created with BioRender.com.