Diverticulosis and Diverticular Disease
Asymptomatic diverticulosis does not require treatment (Telem 2009; Sopena 2011). However, several preventive measures may reduce the risk that diverticulosis will progress to diverticular disease. These include eating a diet high in fiber and low in animal-based foods; getting adequate physical activity; not smoking; restricting alcohol intake; limiting use of non-steroidal anti-inflammatory drugs, steroids, and opiate painkillers; and maintaining a healthy weight (Strate 2012; Bugiantella 2015).
Traditionally, uncomplicated diverticulitis has been treated with broad-spectrum antibiotics and a liquid diet (Ferri 2015). However, the use of antibiotics in uncomplicated or mild diverticulitis has recently been called into question because new evidence suggests they may be unnecessary (de Korte 2011; Hjern 2007; Collins 2015). There is an emerging consensus in the scientific literature that treating mild uncomplicated diverticulitis with antibiotics has no benefit in terms of speeding recovery or preventing complications and recurrences (de Korte 2011; Hjern 2007; Collins 2015; Wilkins 2013).
Recommendations for conservative treatment usually include outpatient management with a liquid or low-residue diet (ie, low in fiber and other foods that increase bowel activity such as dairy), sometimes called bowel rest, and oral antibiotics if symptoms persist but do not worsen over three days (Wilkins 2013; Thaha 2015; Ferri 2015). Surgery is rarely considered necessary for uncomplicated diverticulitis; it is reserved for cases that do not respond to medical management, based on individualized risk analysis (Humes 2014; Wilkins 2013).
In light of new evidence and the evolving model of diverticular disease as an inflammatory condition associated with a disturbed bowel flora, newer treatments are increasingly being used in mild and uncomplicated cases and to prevent recurrence (Humes 2014). These therapies, including non-systemically absorbed antibiotics and probiotics, are described in the Novel and Emerging Therapies and Integrative Interventions sections of this protocol.
In complicated diverticulitis, hospitalization with intravenous fluids and antibiotics may be required. A localized abscess may be drained using CT-guided percutaneous drainage. Diagnostic imaging is recommended to assess severity and identify complications, which could include abscess, perforation, fistula, or stricture (Wilkins 2013).
Surgery is usually reserved for those with abscesses, perforations, fistulas, obstructions, or multiple recurrences, and those who do not respond to appropriate medical treatment. Abdominal surgery can be performed either laparoscopically or as traditional open surgery. Bowel resection may be performed, though more conservative methods such as laparoscopic intraperitoneal lavage (washing) and percutaneous drainage are increasingly favored, especially for low-grade abscesses. These less-invasive procedures result in shorter hospitalizations, fewer complications, and better in-hospital survival (Franklin 2008; Wilkins 2013; Ferri 2015; Morris 2014; Medina-Fernandez 2015).