Authors: Sophie Williams, Ingvar Bjarnason, Bu’Hussain Hayee, Amyn Haji
Journal: Frontline Gastroenterology
Year: 2024
Volume: 15
Pages: 50–58
DOI: 10.1136/flgastro-2022-102361
Study at a glance
- Study type: Narrative review
- Topic: Diverticular disease pathophysiology, classification systems, and treatment approaches
- Focus areas: Diet, lifestyle factors, medical treatments, endoscopic techniques, and surgical management
- Key populations discussed: Western populations with diverticular disease, particularly those with acute diverticulitis and symptomatic uncomplicated diverticular disease
- Main treatments reviewed: Antibiotics, rifaximin, mesalazine, probiotics, endoscopic clipping, and surgical procedures
- Principal findings: Several traditional approaches to diverticular disease management have been challenged by recent evidence
Why was this study done?
Diverticular disease affects approximately 70% of people in western countries by age 80 and is increasingly common in younger age groups, creating substantial healthcare burden. Between 10% and 25% of people develop acute diverticulitis, with 15% experiencing serious complications including abscess formation, bleeding, or perforation. Many also experience chronic symptoms resembling irritable bowel syndrome without active inflammation. The authors undertook this review to summarise current understanding of disease development, classification, and evidence-based treatment approaches.
How was the study performed?
This narrative review examined research on underlying causes including diet, lifestyle factors, structural bowel changes, genetics, and gut bacteria. The authors reviewed classification systems (Hinchey, modified Hinchey, and endoscopic classifications) and evaluated evidence for various treatments through randomised controlled trials, systematic reviews, and meta-analyses. The review considered both prevention and management of acute diverticulitis and chronic symptoms.
What did the researchers find?
Diet plays an important role in diverticular disease. One study of over 47,000 people found those eating the most fibre had 41% lower risk compared to those eating least. Vegetarian diets were linked to 30% reduction in risk. Regular vigorous exercise, healthy body mass index, and not smoking all reduce diverticulitis risk, whilst regular non-steroidal anti-inflammatory drugs, aspirin (other than for medical reasons), and opioid use increase risk.
Multiple randomised controlled trials challenged traditional antibiotic use in uncomplicated diverticulitis. One study of 623 patients found antibiotics did not speed recovery. Another involving 528 patients showed no difference in recovery time, readmission rates, or surgical need between those given antibiotics and those managed without them. Hospital stays were shorter without antibiotics.
For rifaximin, evidence was mixed. Some studies suggested benefit for chronic symptoms when combined with high fibre diet, but insufficient evidence supported its use for preventing diverticulitis episodes.
Mesalazine may help chronic symptoms in some patients. One study of 210 people found 93% symptom resolution with mesalazine compared to 54% with placebo. However, multiple reviews found no convincing evidence mesalazine prevents recurrent acute diverticulitis.
Evidence for probiotics was limited by varied bacterial strains and methods used across studies.
Most serious complications occur during the first episode rather than recurrent attacks. Overall recurrence risk is approximately 20%, with 8% experiencing another episode within one year.
Regarding surgical management, percutaneous drainage guided by radiology is now preferred over surgery for accessible abscesses. Emergency surgery is reserved for patients with widespread peritonitis or those not responding to medical treatment. Up to 25% of patients continue experiencing abdominal pain after surgery, which does not guarantee prevention of further episodes.
What did the authors conclude?
Williams and colleagues concluded that several traditional beliefs about managing diverticular disease should be reconsidered. Most importantly, antibiotics should be used selectively in uncomplicated diverticulitis rather than routinely, recommended for immunocompromised patients or complicated disease only.
Elective surgery should not be offered routinely based on number of episodes. Decisions should be individualised considering patient preferences, quality of life impact, and other medical conditions.
Whilst rifaximin and mesalazine showed some promise for chronic symptoms, no conclusive evidence supports their use preventing recurrent diverticulitis.
Patients should be encouraged to adopt healthy lifestyles with balanced, fibre-rich diets. Contrary to previous advice, consumption of popcorn, nuts, corn, and seeds is not associated with increased risk and may be protective.
Further research is needed, particularly regarding prophylactic endoscopic clipping of diverticula.
Key takeaways
- Antibiotics should be used selectively in uncomplicated diverticulitis, primarily for people with weakened immune systems or complicated disease, rather than routinely for all patients.
- Elective surgery for diverticular disease should be decided individually based on symptoms, quality of life impact, and patient preference, not automatically after a certain number of episodes.
- A high fibre, vegetarian diet, regular vigorous exercise, healthy body weight, and avoiding smoking may reduce the risk of diverticulitis.
- Most serious complications of diverticulitis occur during the first episode rather than with subsequent attacks, with an overall recurrence risk of approximately 20%.
- Current evidence does not support the routine use of mesalazine or rifaximin to prevent recurrent diverticulitis, though they may help some people with chronic symptoms.
This Scientific Publication Summary is an objective summary of the published study for personal and educational use. It does not constitute medical advice, endorsement of the intervention, or a recommendation to alter clinical practice.