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CLINICAL

Diverticular disease practice points


William McSweeney, Havish Srinath

D
Background iverticulosis, the presence of small The mainstay of management for patients
outpouchings of the intestinal wall with uncomplicated severe diverticulitis
Diverticular disease and its spectrum (diverticula), occurs in 10% of people includes bowel rest and broad-spectrum
of complications are increasingly over the age of 45 years and 65% of antibiotics (Figure1).
encountered in the Australian population. those aged over 70 years. It affects men Following an acute presentation of
Accurate management of patients
and women equally and increases with diverticulitis, colonoscopy is generally
before and after an acute episode entails
age.1 Diverticulosis is thought to develop undertaken to exclude neoplasia.4
extension beyond the acute event to
when pressure-induced diverticula form Involvement of a dietitian and advice
include dietary advice and colonoscopy.
in the intestinal wall. The sigmoid colon regarding a high-fibre diet and avoidance
Objectives experiences the highest intracolonic of nuts, seeds and corn is employed
pressures and is the most common site to reduce symptoms and prevent
The objectives of this article are to of diverticulosis. Any region of the colon recurrence.1,4 In this article we review
evaluate the literature regarding dietary can be affected, but diverticulosis is the evidence regarding the utility of a
factors and diverticular disease, routine more prevalent in the right colon in Asian high-fibre diet, avoidance of nuts, seeds
colonoscopy and antibiotic treatment in populations.2,3 and corn, the necessity of colonoscopy
acute diverticulitis, to enable primary care Diverticular disease encompasses following CT-diagnosed diverticulitis, and
physicians to manage patients and provide the spectrum of presentations and the utility of antibiotics.
sound advice after hospital admission.
complications of diverticulosis. It is
proposed that diverticular disease is related Aetiology and presentation
Discussion
to a low intake of fibre.2 Among those The mechanism underlying diverticulosis
Diverticulitis can often be managed in affected, only 1520% are symptomatic; of is understood to involve pressure-induced
the community by general practitioners, those who are symptomatic, onequarter formation of diverticula in the colonic
but the necessity of antibiotics may develop inflammation of the colonic mucosa at intrinsically weak points
not be definitive. When patients do diverticula (diverticulitis) and, uncommonly, where arterioles penetrate the circular
require hospital admission, advice and massive diverticular bleeding.3 The muscle layer to supply the mucosa.
management of patient lifestyle factors preferred modality for diagnosis of These arterioles arise as the inferior
after admission, and investigations to rule diverticulitis is computed tomography (CT) and superior mesenteric arteries form
out red flags are crucial. These elements with intravenous contrast.3 collaterals through the arc of Riolan and
of patient management are the subject of Diverticulitis can be stratified as the marginal artery of Drummond and a
debate, as it appears that standard dietary uncomplicated or complicated on the series of arcades. The terminal arcades
advice does not alter a patients clinical
basis of whether complications such then penetrate the muscular layer as vasa
course, and colonoscopy is not always
as fistula, perforation, obstruction or recti to form the submucosal plexus.
necessary and should be used judiciously.
massive diverticular bleeding are present. Diverticular formation is primarily due
In uncomplicated diverticulitis, severe to raised intracolonic pressures, most
disease is differentiated from moderate commonly in the sigmoid colon. Low-fibre
disease by evidence of systemic infection, Western diets predispose to prolonged
peritonitis, inability to tolerate oral intake colonic transit, increased water resorption
or failure of outpatient management. and low stool bulk, thereby increasing
Other signs of severe disease include colonic pressures.5,6 The natural history
persistent fever or leukocytosis, or of diverticula ranges from asymptomatic
worsening pain after two to three days. to symptomatic diverticular disease and,

The Royal Australian College of General Practitioners 2017 REPRINTED FROM AFP VOL.46, NO.11, NOVEMBER 2017 829
CLINICAL DIVERTICULAR DISEASE PRACTICE POINTS

diverticulitis should undergo colonoscopy


Diverticulitis to exclude malignancy. However, data
to support such a recommendation are
scarce.8 This recommendation is primarily
History/exam: LLQ pain,
altered bowel habits, based on expert opinion, with the rationale
fever, tenderness and of excluding malignancy that mimics acute
localised peritonitis diverticulitis. It stems from a time when
less sensitive and specific techniques
CT IV and
were used, including physical examination
oral contrast
and barium enema.
With the use of contrast-enhanced CT,
the recommendation for colonoscopy
Complicated Uncomplicated Mild may no longer be valid.7,9 Systematic
reviews and meta-analyses suggest
that the risk of colorectal malignancy
is low in patients with uncomplicated
CT-diagnosed acute diverticulitis.10 A
Admission large case-control study found that
diverticulitis did not increase the risk of
being diagnosed with colorectal cancer
in the long term, and that the increased
Oral antibiotics +
IV antibiotics Severe risk within 12 months of diverticulitis may
clinical review
be due to misclassification and increased
surveillance. Furthermore, colon cancer
Percutaneous mortality was unaffected by a history of
drainage diverticular disease.11 A systematic review
Consideration found that the prevalence of colon cancer
of operative in those with CT-diagnosed diverticulitis
Operative intervention if was low and more closely approximates
intervention recurrent episodes the prevalence in the asymptomatic
general population. With the diagnostic
accuracy of CT for acute diverticulitis, the
recommendation of follow-up colonoscopy
Figure 1. Algorithm of assessment, diagnosis and management of diverticulitis
CT, computed tomography; IV, intravenous; LLQ, left lower quadrant
may not be justified.7
Two further systematic reviews
found that the risk of malignancy after
radiologically proven diverticulitis is low,
finally, complications such as diverticulitis diarrhoea, fever and localised peritonitis. and proposed that in the absence of other
or diverticular bleeding. Diagnosis is typically made with indications, routine colonoscopy may not
Symptomatic diverticular disease is intravenous contrast-enhanced CT; be necessary. A more selective approach
typified by abdominal pain and irregular however, interval colonoscopy is based on higher risk features should be
bowel habits. Diverticulitis is hypothesised recommended because neoplasia can used. Such features include abscess,
to be due to obstruction of the diverticula present with similar features clinically localised lymphadenopathy, relative
neck by faecolith, which causes localised and radiographically.7 Non-contrast CT absence of diverticula, focal mass effect
bacterial overgrowth and inflammation. is suboptimal and may result in further or more than one site of inflammation (fat
The ensuing oedema and inflammatory imaging being required. stranding) on CT.10,12 Several retrospective
infiltrate then lead to localised perforation, studies had similar findings, suggesting
which can be contained by adjacent Colonoscopy after that those with diverticular complications,
bowel or omentum, or can progress to diverticulitis such as abscess or fistula, are at higher
generalised peritonitis.1 Most gastroenterology and colorectal risk of malignancy than those with
A typical presentation of diverticulitis surgical publications recommend that uncomplicated diverticulitis, and should
includes left lower quadrant pain, patients presenting with CT-diagnosed undergo colonoscopy.8,13

830 REPRINTED FROM AFP VOL.46, NO.11, NOVEMBER 2017 The Royal Australian College of General Practitioners 2017
DIVERTICULAR DISEASE PRACTICE POINTS CLINICAL

It should be noted, however, that foods on the occurrence of diverticulitis. hospital admissions, as well as the
age-appropriate colonoscopic screening This study, involving more than 47,000 high prevalence in Westernised
should occur in patients with risk factors health professionals in a prospective countries, reductions in the occurrence
who present after uncomplicated cohort design, found no increased risk of of diverticulitis can have far-reaching
diverticulitis. This includes patients diverticulosis or diverticular complications implications for the healthcare system.
who have had a positive faecal occult in those consuming these foods.4 Since With respect to reducing the occurrence
blood test or those with an elevated the HPFS, there have not been any further of diverticulosis in the first instance, the
risk of colorectal cancer because they reliable data addressing this issue. evidence is less clear. Early observational
have a first-degree relative diagnosed Given the paucity of evidence data found lower rates of diverticulosis
with colorectal cancer before 55 years surrounding the dietary claims about in populations with a higher intake of
of age or two first-degree or one first- avoidance of foods such as nuts, seeds fibre.17,18 However, a cross-sectional study
degree and one second-degree relative and corn, and the numerous health in 2012 found that a high-fibre diet actually
diagnosed with colorectal cancer on the benefits of some of these foods, this increased the risk of asymptomatic
same side of the family.7 standard dietary advice should be diverticulosis.19 It seems that evidence
Overall, the available evidence suggests considered carefully. We recommend that is lacking to suggest that a high intake
that while malignancy cannot be entirely patients should not be instructed to avoid of dietary fibre actually reduces the
excluded in all cases of uncomplicated these foods to reduce risk. development of diverticulosis.
CT-diagnosed diverticulitis, the risk of Although a correlation exists between
malignancy is low and routine interval Fibre a low-fibre diet and the development of
colonoscopy in all patients is potentially Dietary advice also includes introducing a diverticular disease and its complications,
not justified. In one systematic review and high-fibre intake into the diet, attempting to a causal link has not been demonstrated
meta-analysis, the proportional estimate reduce intracolonic pressures and colonic conclusively. Given the health benefits of a
of malignancy risk in uncomplicated transit time, thereby reducing the formation high-fibre diet, however, this should still be
diverticulitis was only 0.7%, compared of diverticula and their complications. The recommended despite weak evidence.
with 10.8% in those with complicated evidence for dietary fibre supplementation
diverticulitis.10 comes predominantly from large Antibiotics in diverticulitis
We recommend that colonoscopy is observational and cohort studies, with The most recent point of contention
not necessarily required in patients who very little higher level evidence. However, concerns the utility of antibiotics in
are being followed up after uncomplicated randomised controlled trials are generally treating diverticulitis. With the rise of
diverticulitis. A more selective approach to not feasible at these population-level antibiotic resistance and the potential
the use of colonoscopy, such as for those associations. The European Prospective healthcare budget savings of treating
with high-risk features, personal preference Investigation into Cancer and Nutrition uncomplicated diverticulitis with only
or family history, is more appropriate. (EPIC)-Oxford study, using a cohort design, bowel rest, studies have begun to address
followed more than 47,000 men and this issue.
Dietary factors women. This study found that a higher Uncomplicated diverticulitis refers to
intake of dietary fibre was associated the absence of complications, such as
Avoidance with lower rates of diverticular disease perforation or fistula, as defined earlier
Once the acute episode of diverticulitis (including diverticulitis and bleeding) and in this article. Early trials suggested that
is treated, the mainstay of advice on lower rates of hospitalisation.14 acute uncomplicated diverticulitis can
discharge is to increase the intake of The HPFS also found a strong inverse be safely treated without antibiotics
dietary fibre and avoid foods that could relationship between dietary fibre and that this management does not
predispose to a further episode of intake and symptomatic diverticular increase further events of diverticulitis.20
diverticulitis, mainly corn, nuts and seeds. disease.4,15 There is also evidence for However, international guidelines
This stems from the theory that luminal significantly fewer complications and a include the recommendation of oral or
trauma is a causal mechanism that relates lower requirement for surgery in patients intravenous antibiotics, which is largely
to diverticulitis and diverticular bleeding. who are on a high-fibre diet.16 It seems based on expert opinion.21 Recently,
The assumption is that foods such as reasonable, therefore, to continue to studies have found that management
nuts, seeds or corn can obstruct the recommend a high-fibre diet for patients without antibiotics is indeed safe and
neck of a diverticulum and precipitate who have had an episode of diverticular not associated with an increased risk
diverticulitis.4 The Health Professional complications. of adverse events, which tend to be
Follow-up Study (HPFS) is the first major Given the large economic cost of more prevalent in patients with high-risk
study to assess the effect of these diverticular disease and its associated complicated diverticulitis.22,23

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CLINICAL DIVERTICULAR DISEASE PRACTICE POINTS

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