Management of Colonic Diverticular DiseaseFrieri G.a · Pimpo M.T.a · Scarpignato C.b
aGastroenterology Unit, School of Medicine and Dentistry, University of L’Aquila, L’Aquila, and bLaboratory of Clinical Pharmacology, Department of Anatomy, Pharmacology and Forensic Sciences, University of Parma, Parma, Italy
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Diverticular disease of the colon is a complex syndrome that includes several clinical conditions, each needing different therapeutic strategies. In patients with asymptomatic diverticulosis, only a fiber-rich diet can be recommended in an attempt to reduce intraluminal pressure and slow down the worsening of the disease. Fiber supplementation is also indicated in symptomatic diverticulosis in order to get symptom relief and prevent acute diverticulitis. In this regard, the best results have been obtained by combination of soluble fiber, like glucomannan, and poorly absorbed antibiotics, like rifaximin, given 7–10 days every month. For uncomplicated diverticulitis the standard therapy is liquid diet and oral antimicrobials, usually ciprofloxacin and metronidazole. Hospitalization, bowel rest, and intravenous antibacterial agents are mandatory for complicated diverticulitis. Haemorrhage is usually a self-limited event but may require endoscopic or surgical treatment. Once in remission, continuous fiber intake and intermittent course of rifaximin may improve symptoms and reduce diverticulitis recurrence. These preventive strategies will likely improve patients’ quality of life and reduce management costs. A surgical approach in diverticular disease is needed in 15–30% of cases and consists of removing the intestinal segment affected by diverticula. It is indicated in diffuse peritonitis, abscesses, fistulas, stenosis and after the second to fourth attack of uncomplicated diverticulitis. Young people and immunocompromised patients are more likely to be operated.
© 2006 S. Karger AG, Basel
- Trotman IF, Misiewicz JJ: Sigmoid motility in diverticular disease and the irritable bowel syndrome. Gut 1988;29:218–222.
- Sugihara K, Muto T, Morioka Y: Motility study in right-sided diverticular disease of the colon. Gut 1983;24:1130–1134.
- Painter NS, Truelove SC, Ardran GM: Segmentation and localization of intraluminal pressures in the human colon, with special reference to the pathogenesis of colonic diverticula. Gastroenterology 1965;49:169–177.
- Painter NS, Burkitt DP: Diverticular disease of the colon: a deficiency disease of western civilization. Br Med J 1971;ii:450–454.
- Burkitt DP, Walker ARP, Painter NS: Effect of dietary fibre on stools and transit times, and its role in the causation of disease. Lancet 1972;ii:1408–1411.
- Baird IM, Walters RL, Davies PS, Hill MJ, Drasar BS, Southgate DA: The effects of two dietary fiber supplementation on gastrointestinal transit, stool weight and frequency, bacterial flora and fecal bile acids in normal subjects. Metabolism 1977;26:117–128.
- Aldoori WH, Giovannucci EL, Rockett HR, Sampson L, Rimm EB, Willett WC: A prospective study of dietary fiber types and symptomatic diverticular disease in men. J Nutr 1998;128:714–719.
- Francis CY, Whorwell P: Bran and irritable bowel syndrome: time for reappraisal. Lancet 1994;344:39–40.
- Bijkerk CJ, Muris JW, Knottnerus JA, Hoes AW, de Wit NJ: Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 2004;19:245–251.
- Stollman N, Raskin JB: Diverticular disease of the colon. Lancet 2004;363:631–639.
Parra-Blanco A: Colonic diverticular disease: pathophysiology and clinical picture. Digestion 2006;73(suppl 1)41–50.
- Brodribb AJM: Treatment of symptomatic diverticular disease with a high fibre diet. Lancet 1977;i:664–665.
- Ornstein MH, Littlewood ER, Baird IM, Fowler J, North WR, Cox AG: Are fiber supplements really necessary in diverticular disease of the colon? A controlled clinical trial. Br Med J 1981;282:1353–1356.
Stollman NH, Raskin B: Diagnosis and management of diverticular disease of the colon in adults Am J Gastroenterol 1999;94:3110–3121.
- Daniel O, Basup K, Al-Samarrae HM: Use of glucagon in the treatment of acute diverticulitis. Br Med J 1974;iii:720–722.
- Levitt MD, Bond JH: Volume, composition and source of intestinal gas. Gastroenterology 1970;59:921–929.
Strocchi A, Levitt MD: Intestinal gas; in Sleisenger MH, Fordtran JS (eds): Gastrointestinal Disease: Pathophysiology, Diagnosis, Management, ed 5. Philadelphia, Saunders, 1993, pp 1035–1042.
- Bjorneklett A, Midvedt T: Influence of three antimicrobial agents – penicillin, metronidazole and doxycyclin – on the intestinal microflora of healthy humans. Scand J Gastroenterol 1981;16:473–480.
- Rao SS, Edwards CA, Austen CJ, Bruce C, Read NW: Impaired colonic fermentation of carbohydrate after ampicillin. Gastroenterology 1988;94:928–932.
- Di Stefano M, Strocchi A, Malservisi S, Veneto G, Ferrieri A, Corazza GR: Non-absorbable antibiotics for managing intestinal gas production and gas-related symptoms. Aliment Pharmacol Ther 2000;14:1001–1008.
Corazza GR, Di Stefano M, Scarpignato C: Treatment of functional bowel disorders: is there room for antibiotics? Digestion 2006;73(suppl 1):33–40.
- Kurpad AV, Shetty PS: Effects of antimicrobial therapy on fecal bulking. Gut 1986;27:55–58.
- Papi C, Koch M, Capurso L: Management of diverticular disease: is there room for rifaximin? Chemotherapy 2005;51(suppl 1):110–114.
- Scarpignato C, Pelosini I: Experimental and clinical pharmacology of rifaximin, a gastrointestinal selective antibiotic. Digestion 2006;73(suppl 1):13–27.
- Papi C, Ciaco A, Koch M, Capurso L, Camarri E, Ferrieri A, Guardascione F, Miglio F, Minoli G, Terruzzi V, Parodi MC, Riegler G, Russo A: Efficacy of rifaximin of symptoms of uncomplicated diverticular disease of the colon. A pilot multicenter open trial. Ital J Gastroelterol 1992;24:452–456.
- Latella G, Pimpo MT, Sottili S, Zippi M, Viscido A, Chiaramonte M, Fieri G: Rifaximin improves symptoms of acquired uncomplicated diverticular disease of the colon. Int J Colorectal Dis 2003;18:55–62.
Papi C, Ciaco A, Koch M, Capurso L, Diverticular Disease Study Group: Efficacy of rifaximin in the treatment of symptomatic diverticular disease of the colon. A multicentre double-blind placebo-controlled trial Aliment Pharmacol Ther 1995;9:33–39.
- Di Mario F, Aragona G, Leandro G, Comparato G, Fanigliulo L, Cavallaro LG, Cavestro GM, Iori V, Maino M, Moussa AM, Gnocchi A, Mazzocchi G, Franze A: Efficacy of mesalazine in the treatment of symptomatic diverticular disease. Dig Dis Sci 2005;50:581–586.
- Tursi A, Brandimarte G, Daffinà R: Long-term treatment with mesalazine and rifaximin versus rifaximin alone for the patients with recurrent attacks of acute diverticulitis of the colon. Digest Liver Dis 2002;34:510–515.
Chow A: Appendicitis and diverticulitis; in Hoeprich PD, Jordan MC, Ronald AL (eds): Infectious Disease: A Treatise of Infectious Processes. Philadelphia, Lippincott, 1994, pp 878–881.
- Roberts PL, Veidenheimer MC: Current management of diverticulitis. Adv Surg 1994;27:189–208.
- Standards Task Force of the American Society of Colon and Rectal Surgeons: Practice parameters for sigmoid diverticulitis: supporting documentation. Dis Colon Rectum 1995;38:126–132.
Parks TG: Natural history of diverticular disease of the colon: a review of 521 cases. BMJ 1969;iv:639–642.
- Ferzoco LB, Raptopoulos V, Silen W: Acute diverticulitis. N Engl J Med 1998;338:1521–1526.
- Kellum JM, Sugerman HJ, Coppa GF, Way LR, Fine R, Herz B, Speck EL, Jackson D, Duma RJ: Randomized prospective comparison of cefoxitin and gentamycin-clindamycin in the treatment of acute colon diverticulitis. Clin Ther 1992;14:376–384.
- Drusano GL, Warren JW, Saah AJ, Caplan ES, Tenney JH, Hansen S, Granados J, Standiford HC, Miller EH Jr: A prospective randomized controlled trial of cefoxitin versus clindamycin-aminoglycoside in mixed anaerobic-aerobic infections. Surg Gynecol Obstet 1982;154:715–720.
- Schechter S, Mulvey J, Eisenstat TE: Management of uncomplicated acute diverticulitis: results of a survey. Dis Colon Rectum 1999;42:470–476.
- Berman LG, Burdick D, Heitzman ER, Prior JT: A critical reappraisal of sigmoid peridiverticulitis. Surg Gynecol Obstet 1968;127:481–491.
Williams RA, Davis IP: Diverticular disease of the colon; in Haubrich WS, Schaffner F (eds): Bockus Gastroenterology, ed 5. Philadelphia, Saunders, 1995, pp 1637–1656.
Sanders ME: Probiotics. Food Technol 1999;53:67–77.
- Gionchetti P, Amadini C, Rizzello F, Venturi A, Palmonari V, Morselli C, Romagnoli R, Campieri M: Probiotics – role in inflammatory bowel disease. Digest Liver Dis 2002;34(suppl 2):S58–S62.
- Isolauri E: Probiotics for infectious diarrhoea. Gut 2003;52:436–437.
- Fric P, Zavoral M: The effect of non-pathogenic Escherichia coli in symptomatic uncomplicated diverticular disease of the colon. Eur J Gastroenterol Hepatol 2003;15:313–315.
- Ambrosetti P, Robert J, Witzig JA, Ambrosetti P, Robert J, Witzig JA, Mirescu D, de Gautard R, Borst F, Rohner A: Incidence, outcome, and proposed management of isolated abscesses complicating acute left-sided colonic diverticulitis: a prospective study of 140 patients. Dis Colon Rectum 1992;35:1072–1076.
- Gerzof SG, Robbins AH, Johnson WC, Birkett DH, Nabseth DC: Percutaneous catheter drainage of abdominal abscesses. N Engl J Med 1981;305:653–657.
- Schechter S, Eisenstat TE, Oliver GC, Rubin RJ, Salvati EP: Computed tomographic scan-guided drainage of intra-abdominal abscesses. Dis Colon Rectum 1994;37:984–988.
- Stabile BE, Puccio E, vanSonnenberg E, Neff CC: Preoperative percutaneous drainage of diverticular abscesses. Am J Surg 1990;159:99–105.
- Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J: Surgical management of complicated colonic diverticulitis. Br J Surg 1997;84:380–383.
- Franklin ME, Dorman JP, Jacobs M, Plasencia G: Is laparoscopic surgery applicable to complicated colonic diverticular disease? Surg Endosc 1997;11:1021–1025.
- Yoshida M, Mitsuo M, Kutsumi H, Fujita T, Soga T, Nishimura K, Kawabata K, Kadotani Y, Kinoshita Y, Chiba T, Kuroiwa N, Fujimoto S: A successfully treated case of multiple liver abscesses accompanied by portal venous gas. Am J Gastroenterol 1996;91:2423–2425.
- Nosher JL, Guidici M, Needell GS, Brolin RE: Elective one-stage abdominal operations after percutaneous catheter drainage of pyogenic liver abscess. Am Surg 1993;59:658–663.
- Read DR, Hambrick E: Hepatic abscesses in diverticulitis. South Med J 1980;73:881–883.
- Hinchey EF, Schaal PG, Richards GK: Treatment of perforated diverticular disease of the colon. Adv Surg 1978;12:85–109.
- Tudor RG, Keighley MR: The options in surgical treatment of diverticular disease. Surg Annu 1987;19:135–149.
- Krukowski ZH, Matheson NA: Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review. Br J Surg 1984;71:921–927.
- Reinus JF, Brandt LJ: Vascular ectasias and diverticulosis: Common causes of lower intestinal bleeding. Gastroenterol Clin North Am 1994;23:1–20.
- McGuire HH, Haynes BW: Massive hemorrhage from diverticulosis of the colon: guidelines for therapy based on bleeding patterns observed in 50 cases. Ann Surg 1972;175:847–855.
- Mauldin JL: Therapeutic use of colonoscopy in active diverticular bleeding. Gastrointest Endosc 1985;31:290–291.
- Johnston J, Sones J: Endoscopic heater probe coagulation of the bleeding colonic diverticulum. Gastrointest Endosc 1986;32:A160.
- Savides TJ, Jensen DM: Colonoscopic hemostasis for recurrent diverticular hemorrhage associated with a visible vessel: a report of three cases. Gastrointest Endosc 1994;40:70–73.
- Bertoni G, Conigliaro R, Ricci E, Mortilla MG, Bedogni G, Fornaciari G: Endoscopic injection hemostasis of colonic diverticular bleeding: a case report. Endoscopy 1990;22:154–155.
- Kim YI, Marcon NE: Injection therapy for colonic diverticular bleeding: a case study. J Clin Gastroenterol 1993;17:46–48.
- Andress HJ, Mewes A, Lange V: Endoscopic hemostasis of a bleeding diverticulum of the sigma (sic) with fibrin sealant. Endoscopy 1993;25:193.
- Foutch PG: Diverticular bleeding: are nonsteroidal anti-inflammatory drugs risk factors for hemorrhage and can colonoscopy predict outcome for patients? Am J Gastroenterol 1995;90:1779–1784.
- Foutch PG: Diverticular bleeding and the pigmented protuberance (sentinel clot): clinical implications, histopathological correlation, and results of endoscopic intervention. Am J Gastroenterol 1996;91:2589–2593.
- Foutch PG: Utility of endoscopic hemoclipping for colonic diverticular bleeding (response to Dr. Hokama). Am J Gastroenterol 1997;92:543–545.
- Browder W, Cerise EJ, Litwin MS: Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg 1986;204:530–536.
Sleisenger & Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. Philadelphia, Saunders, 2002, pp 2100–2112.
- Elliot TB, Yego S, Irvin TT: Five-year audit of the acute complications of diverticular disease. Br J Surg 1997;84:535–539.
- Almy TP, Howell DA: Diverticular disease of the colon. N Engl J Med 1980;302:324–331.
- Munson KD, Hensien MA, Jacob LN, et al: Diverticulitis. A comprehensive follow-up. Dis Colon Rectum 1996;39:318–322.
- Chodak GW, Rangel DM, Passaro E Jr: Colonic diverticulitis in patients under age 40: need for earlier diagnosis. Am J Surg 1981;141:699–702.
- Eusebio EB, Eisenberg MM: Natural history of diverticular disease of the colon in young patients. Am J Surg 1973;125:308–311.
- Freischlag J, Bennion RS, Thompson JE Jr: Complications of diverticular disease of the colon in young people. Dis Colon Rectum 1986;29:639–643.
- Spivak H, Weinrauch S, Harvey JC, Surick B, Ferstenberg H, Friedman I: Acute colonic diverticulitis in the young. Dis Colon Rectum 1997;40:570–574.
- Vignati PV, Welch JP, Cohen JL: Long-term management of diverticulitis in young patients. Dis Colon Rectum 1995;38:627–662.
- Berry AR, Turner WH, Mortensen NJ, Kettlewell MG: Emergency surgery for complicated diverticular disease: a five-year experience. Dis Colon Rectum 1989;32:849–854.
- Frizelle FA, Dominguez JM, Santoro GA: Management of post-operative recurrent diverticulitis: a review of the literature. J R Coll Surg Edinb 1997;42:186–188.
- Parks TG, Connell AM: The outcome in 455 patients admitted for treatment of diverticular disease of the colon. Br J Surg 1970;57:775–778.
- Ulin AW, Pearce AE, Weinstein SF: Diverticular disease of the colon: surgical perspectives in the past decade. Dis Colon Rectum 1981;24:276–281.
- Hackford AW, Schoetz DR Jr, Coller JA, Veidenheimer MC: Surgical management of complicated diverticulitis: the Lahey Clinic experience, 1967–1982. Dis Colon Rectum 1985;28:317–321.
- Sarin S, Boulous PB: Evaluation of current surgical management of acute inflammatory diverticular disease. Ann R Coll Surg Engl 1991;73:278–282.
- Benn PL, Wolff, BG, Ilstrup DM: Level of anastomosis and recurrent colonic diverticulitis. Am J Surg 1986;151:269–271.
Porta A, Germano A, Ferieri A, Koch M: The natural history of diverticular disease of the colon: a role for antibiotics in preventing complications? Eur Rev Med Pharmacol Sci 1994;16:33–39.
Giaccari S, Tronci S, Falconieri M, Ferrieri A: Long-term treatment with rifaximin and lactobacilli in post-diverticulitic stenoses of the colon Eur Rev Med Pharmacol Sci 1993;15:29–34.
- Simpson J, Spiller R: Colonic diverticular disease. Clin Evid 2004;12:599–609.
Zaniolo O, Eandi M: Rifaximin in the treatment of diverticular disease: therapeutic and economic implications (in Italian). Farmacoecon Perc Terap 2005;6:5–20.
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