Review Article
Diverticular Disease: The Old, the New, and the Ever-Changing View
Abstract
Our understanding of diverticular disease has evolved significantly during the last 25 years, and as such, a reexamination is in order. We performed a literature search for the years 1960–2017 of PubMed, Medline, and Google Scholar for updates regarding the epidemiology, risk factors, and therapies for traditional diverticulitis as well as the recently described subtypes of diverticular disease, segmental colitis associated with diverticulosis, and symptomatic uncomplicated diverticular disease. Although the prevalence of diverticulosis is still extremely common in the general population, the literature suggests that the incidence of diverticulitis is much less than previously believed and occurrences do not necessarily increase with age. In addition, the commonly held beliefs that low-fiber diets alone contribute to the development of diverticulosis and diverticulitis have not been verified; however, the combination of a low-fiber diet and a high red meat/high-fat diet is a risk factor for diverticulitis. Surgery continues to be the treatment for severe complications of diverticulitis, but new literature suggests that it has a poor utility in preventing a recurrence of diverticulitis in the long term; therefore, elective surgery after two episodes of diverticulitis is no longer the standard.This content is limited to qualifying members.
Existing members, please login first
If you have an existing account please login now to access this article or view purchase options.
Purchase only this article ($25)
Create a free account, then purchase this article to download or access it online for 24 hours.
Purchase an SMJ online subscription ($75)
Create a free account, then purchase a subscription to get complete access to all articles for a full year.
Purchase a membership plan (fees vary)
Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.
References
1. Peery AF, Barrett PR, Park D, et al. A high-fiber diet does not protect against asymptomatic diverticulosis. Gastroenterology 2012;142:266-372.e1.
2. Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part II: lower gastrointestinal diseases. Gastroenterology 2009;136:741-754.
3. Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol 1975;4:53-69.
4. Shahedi K, Fuller G, Bolus R, et al. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol 2013;11:1609-1613.
5. Strate LL, Modi R, Cohen E, et al. Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights. Am J Gastroenterol 2012;107: 1486-1493.
6. Painter NS, Burkitt DP. Diverticular disease of the colon: a deficiency disease of Western civilization. Br Med J 1971;2:450-454.
7. Painter NS, Truelove SC, Ardran GM, et al. Segmentation and the localization of intraluminal pressures in the human colon, with special reference to the pathogenesis of the colonic diverticula. Gastroenterology 1965;49:169-177.
8. Bassotti G, Battaglia E, Spinozzi F, et al. Twenty-four hour recordings of colonic motility in patients with diverticular disease: evidence for abnormal motility and propulsive activity. Dis Colon Rectum 2001;44: 1814-1820.
9. Katschinski M, Lederer P, Ellermann A, et al. Myoelectric and manometric patterns of human rectosigmoid colon in irritable bowel syndrome and diverticulosis. Scand J Gastroenterol 1990;25:761-768.
10. Hong W, Geng W, Wang C, et al. Prevalence of colonic diverticulosis in mainland China from 2004 to 2014. Sci Rep 2016;6:26237.
11. Crowe FL, Appleby PN, Allen NE, et al. Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians. BMJ 2011;343:d4131.
12. Crowe FL, Balkwill A, Cairns BJ, et al. Source of dietary fibre and diverticular disease incidence: a prospective study of UK women. Gut 2014;63:1450-1456.
13. Aldoori WH, Giovannucci EL, Rimm EB, et al. A prospective study of diet and the risk of symptomatic diverticular disease in men. Am J Clin Nutr 1994;60:757-764.
14. Aldoori WH, Giovannucci EL, Rimm EB, et al. A prospective study of alcohol, smoking, caffeine, and the risk of symptomatic diverticular disease in men. Ann Epidemiol 1995;5:221-228.
15. Hjern F, Wolk A, Håkansson N. Smoking and the risk of diverticular disease in women. Br J Surg 2011;98:997-1002.
16. Aldoori WH, Giovannucci EL, Rimm EB, et al. Prospective study of physical activity and the risk of symptomatic diverticular disease in men. Gut 1995;36:276-282.
17. Hjern F, Wolk A, Håkansson N. Obesity, physical inactivity, and colonic diverticular disease requiring hospitalization in women: a prospective cohort study. Am J Gastroenterol 2012;107:296-302.
18. Strate LL, Liu YL, Aldoori WH, et al. Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology 2009;136: 115-122. e1.
19. Strate LL, Liu YL, Huang ES, et al. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology 2011;140:1427-1433.
20. Humes DJ, Fleming KM, Spiller RC, et al. Concurrent drug use and the risk of perforated colonic diverticular disease: a population-based case-control study. Gut 2011;60:219-224.
21. Maguire LH, Song M, Strate LE, et al. Higher serum levels of vitamin D are associated with a reduced risk of diverticulitis. Clin Gastroenterol Hepatol 2013;11:1631-1635.
22. 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.
23. Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. Br Med J 1969;4:639-642.
24. Munson KD, Hensien MA, Jacob LN, et al. Diverticulitis. A comprehensive follow-up. Dis Colon Rectum 1996;39:318-322.
25. Larson DM, Masters SS, Spiro HM. Medical and surgical therapy in diverticular disease: a comparative study. Gastroenterology 1976;71:734-737.
26. Eglinton T, Nguyen T, Raniga S, et al. Patterns of recurrence in patients with acute diverticulitis. Br J Surg 2010;97:952-957.
27. Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg 2005;140:681-685.
28. Broderick-Villa G, Burchette RJ, Collins JC, et al. Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg 2005;140:576-583.
29. Hall JF, Roberts PL, Ricciardi R, et al. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum 2011;54:283-288.
30. Lamps LW, Knapple WL. Diverticular disease-associated segmental colitis. Clin Gastroenterol Hepatol 2007;5:27-31.
31. Tursi A. Segmental colitis associated with diverticulosis: complication of diverticular disease or autonomous entity? Dig Dis Sci 2011;56:27-34.
32. Tursi A, Elisei W, Brandimarte G, et al. The endoscopic spectrum of segmental colitis associated with diverticulosis. Colorectal Dis 2010;12: 464-470.
33. Freeman HJ. Segmental colitis associated diverticulosis syndrome. World J Gastroenterol 2016;22:8067-8069.
34. Mann NS, Hoda KK. Segmental colitis associated with diverticulosis: systematic evaluation of 486 cases with meta-analysis. Hepatogastroenterology 2012;59:2119-2121.
35. Koutroubakis IE, Antoniou P, Tzardi M, et al. The spectrum of segmental colitis associated with diverticulosis. Int J Colorectal Dis 2005;20:28-32.
36. Tursi A, Elisei W, Giorgetti GM, et al. Segmental colitis associated with diverticulosis: a 5-year follow-up. Int J Colorectal Dis 2012;27:179-185.
37. Imperiali G, Terpin MM, Meucci G, et al. Segmental colitis associated with diverticula: a 7-year follow-up study. Endoscopy 2006;38:610-612.
38. Horgan AF, McConnell EJ, Wolff BG, et al. Atypical diverticular disease: surgical results. Dis Colon Rectum 2001;44:1315-1318.
39. Picchio M, Elisei W, Brandimarte G, et al. Mesalazine for the treatment of symptomatic uncomplicated diverticular disease of the colon and for primary prevention of diverticulitis: a systematic review of randomized clinical trials. J Clin Gastroenterol 2016;50(Suppl 1):S64-S69.
40. Korzenik JR. Case closed? Diverticulitis: epidemiology and fiber. J Clin Gastroenterol 2006;40(Suppl 3):S112-S116.
41. Papi C, Ciaco A, Koch M, et al. Efficacy of rifaximin on symptoms of uncomplicated diverticular disease of the colon. A pilot multicentre open trial. Diverticular Disease Study Group. Ital J Gastroenterol 1992;24:452-456.
42. Lamiki P, Tsuchiya J, Pathak S, et al. Probiotics in diverticular disease of the colon: an open label study. J Gastrointestin Liver Dis 2010;19:31-36.
43. Clemens CH, Samsom M, Roelofs J, et al. Colorectal visceral perception in diverticular disease. Gut 2004;53:717-722.
44. Tursi A, Elisei W, Picchio M, et al. Moderate to severe and prolonged left lower-abdominal pain is the best symptom characterizing symptomatic uncomplicated diverticular disease of the colon: a comparison with fecal calprotectin in clinical setting. J Clin Gastroenterol 2015;49:218-221.
45. Harpaz N, Sachar DB. Segmental colitis associated with diverticular disease and other IBD look-alikes. J Clin Gastroenterol 2006;40( Suppl 3 ):S132-S135.
46. Simpson J, Sundler F, Humes DJ, et al. Post inflammatory damage to the enteric nervous system in diverticular disease and its relationship to symptoms. Neurogastroenterol Motil 2009;21:847-e58.
47. Strate LL, Liu YL, Syngal S, et al. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA 2008;300:907-914.
48. Dughera L, Serra AM, Battaglia E, et al. Acute recurrent diverticulitis is prevented by oral administration of a polybacterial lysate suspension. Minerva Gastroenterol Dietol 2004;50:149-153.
49. Tursi A, Brandimarte G, Elisei W, et al. Randomised clinical trial: mesalazine and/or probiotics in maintaining remission of symptomatic uncomplicated diverticular disease-a double-blind, randomised, placebo-controlled study. Aliment Pharmacol Ther 2013;38:741-751.
50. Strate LL, Peery AF, Neumann I. American Gastroenterological Association Institute technical review on the management of acute diverticulitis. Gastroenterology 2015;149:1950-1976.e12.
51. Shanahan F. The neglected spectrum of diverticular-related disorders. Clin Gastroenterol Hepatol 2013;11:1620-1621.
52. Preidis GA, Versalovic J. Targeting the human microbiome with antibiotics, probiotics, and prebiotics: gastroenterology enters the metagenomics era. Gastroenterology 2009;136:2015-2031.
53. Stollman N, Magowan S, Shanahan F, et al. A randomized controlled study of mesalamine after acute diverticulitis: results of the DIVA trial. J Clin Gastroenterol 2013;47:621-629.
54. Parente F, Bargiggia S, Prada A, et al. Intermittent treatment with mesalazine in the prevention of diverticulitis recurrence: a randomised multicentre pilot double-blind placebo-controlled study of 24-month duration. Int J Colorectal Dis 2013;28:1423-1431.
55. Raskin JB, Kamm MA, Jamal MM, et al. Mesalamine did not prevent recurrent diverticulitis in phase 3 controlled trials. Gastroenterology 2014;147:793-802.
56. Kruis W, Eisenbach T, Lohr H, et al. Double-blind, randomized, placebo-controlled, multicenter trial of mesalamine for the prevention of recurrence of diverticulitis. Gastroenterology 2013;144(Suppl 1):S-139.
57. Kruis W, Kardalinos V, Curtin A, et al. Daily mesalamine fails to prevent recurrent diverticulitis in a large placebo controlled multicenter trial. Gastroenterology 2014;147( Suppl 1 ):S-187.
58. Lanas A, Ponce J, Bignamini A, et al. One year intermittent rifaximin plus fibre supplementation vs. fibre supplementation alone to prevent diverticulitis recurrence: a proof-of-concept study. Dig Liver Dis 2013;45:104-109.
59. Chabok A, Påhlman L, Hjern F, et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012;99:532-539.
60. Isacson D, Thorisson A, Andreasson K, et al. Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study. Int J Colorectal Dis 2015;30:1229-1234.
61. Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum 2014;57:284-294.
62. Chapman J, Davies M, Wolff B, et al. Complicated diverticulitis: is it time to rethink the rules? Ann Surg 2005;242:576-583.
63. Chapman JR, Dozois EJ, Wolff BG, et al. Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes? Ann Surg 2006;243:876-883.
64. Ricciardi R, Baxter NN, Read TE, et al. Is the decline in the surgical treatment for diverticulitis associated with an increase in complicated diverticulitis? Dis Colon Rectum 2009;52:1558-1563.
65. Daniels L, Unlu C, de Wijkerslooth TR, et al. Routine colonoscopy after left-sided acute uncomplicated diverticulitis: a systematic review. Gastrointest Endosc 2014;79:378-389.
66. Sharma PV, Eglinton T, Hider P, et al. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg 2014;259:263-272.
67. Neugut AI, Jacobson JS, Rella VA. Prevalence and incidence of colorectal adenomas and cancer in asymptomatic persons. Gastrointest Endosc Clin N Am 1997;7:387-399.
