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Diverticular disease — Clinical Guidelines

Overview

Colonic diverticulosis and diverticular disease are prevalent gastrointestinal disorders characterized by the presence of diverticula in the colon, often leading to complications such as bleeding, inflammation (diverticulitis), and obstruction. 1 4 7

Diagnosis

Clinical Presentation: Abdominal pain, changes in bowel habits, and complications like bleeding or perforation.

Imaging: CT is essential for diagnosing complications such as diverticulitis and assessing severity.

Endoscopy: Useful for diagnosing acute bleeding sites and can be therapeutic with methods like adrenaline injection, clipping, and thermal coagulation. 10 9

Laboratory Tests: Elevated white blood cell count in cases of inflammation.

Fibre Intake Assessment: Evaluating dietary fibre intake may help identify risk factors. 12

Management

Symptomatic Disease: High-fibre diet recommended to manage symptoms and prevent complications. 1 12

Acute Diverticulitis:

- Mild Cases: Conservative management with bowel rest, hydration, and antibiotics (e.g., ciprofloxacin or metronidazole). 1 4 - Severe or Complicated Cases: Early elective surgery may be considered to prevent recurrence and complications. 5 7

Bleeding:

- Initial Management: Bowel rest, hemodynamic stabilization, and selective angiography with embolization if necessary. 9 10 - Antibiotics: Rifaximin may be used for its localized effects in managing symptomatic disease. 6

Preventive Measures: Increasing dietary fibre intake to prevent symptom development. 12

Special Populations

Elderly: Higher risk of complications and poorer outcomes; close monitoring and individualized treatment plans are crucial. 8

Comorbidities: Patients with comorbidities like cardiovascular disease may require tailored surgical and medical interventions to manage diverticular disease effectively. 8

Key Recommendations

Dietary Fibre: Increase dietary fibre intake to manage and prevent symptomatic diverticular disease. (Evidence: Strong 1 12)

Conservative vs. Surgical Management: For acute diverticulitis, initial conservative management with antibiotics is recommended for mild cases; early elective surgery should be considered for severe or recurrent cases. (Evidence: Moderate 5 7)

Endoscopic Intervention: Endoscopy can be both diagnostic and therapeutic for acute diverticular bleeding, utilizing techniques such as adrenaline injection and clipping. (Evidence: Moderate 10 9)

Rifaximin Use: Consider rifaximin for symptomatic management due to its localized effects in the gastrointestinal tract. (Evidence: Expert opinion 6)

Close Monitoring in Elderly: Elderly patients require close monitoring due to higher complication risks and poorer outcomes. (Evidence: Moderate 8)

References

1 Carabotti M, Sgamato C, Amato A, Beltrame B, Binda GA, Germanà B et al.. Italian guidelines for the diagnosis and management of colonic diverticulosis and diverticular disease. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2024. link 2 Gavriilidis P, Askari A, Gavriilidis E, de'Angelis N, Di Saverio S, Wheeler J et al.. Appraisal of the current guidelines for the management of diverticular disease using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument. Annals of the Royal College of Surgeons of England 2021. link 3 Arabi NA, Musaad AM, Mohammed FAH, Ahmed EE, Abdelaziz MSE. Acute lower gastrointestinal bleeding in Sudanese patients: a study on 301 patients in a specialized centre. Arab journal of gastroenterology : the official publication of the Pan-Arab Association of Gastroenterology 2018. link 4 Trifan A, Gheorghe C, Marica Sabo C, Diculescu M, Nedelcu L, Singeap AM et al.. Diagnosis and Treatment of Colonic Diverticular Disease: Position Paper of the Romanian Society of Gastroenterology and Hepatology. Journal of gastrointestinal and liver diseases : JGLD 2018. link 5 Warwas FB, Schneider B. Elective vs. early elective surgery in diverticular disease: a retrospective study on the optimal timing of non-emergency treatment. International journal of colorectal disease 2018. link 6 Cuomo R, Barbara G, Annibale B. Rifaximin and diverticular disease: Position paper of the Italian Society of Gastroenterology (SIGE). Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2017. link 7 Kruis W, Germer CT, Leifeld L. Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery. Digestion 2014. link 8 Jeyarajah S, Faiz O, Bottle A, Aylin P, Bjarnason I, Tekkis PP et al.. Diverticular disease hospital admissions are increasing, with poor outcomes in the elderly and emergency admissions. Alimentary pharmacology & therapeutics 2009. link 9 Hizawa K, Miura N, Matsumoto T, Iida M. Colonic diverticular bleeding: precise localization and successful management by a combination of CT angiography and interventional radiology. Abdominal imaging 2009. link 10 Pilichos C, Bobotis E. Role of endoscopy in the management of acute diverticular bleeding. World journal of gastroenterology 2008. link 11 Colecchia A, Sandri L, Capodicasa S, Vestito A, Mazzella G, Staniscia T et al.. Diverticular disease of the colon: new perspectives in symptom development and treatment. World journal of gastroenterology 2003. link 12 Brodribb AJ, Humphreys DM. Diverticular disease: three studies. Part I--Relation to other disorders and fibre intake. British medical journal 1976. link

Diverticular disease