Preventing Recurrent Diverticulitis

Diverticulitis, which is inflammation of small pouches (diverticuli) that form in the colon, accounts for over 300,000 hospitalizations per year in the United States.[1][2][3] It is the third most common gastrointestinal (GI) problem requiring hospitalization and is tied to many colectomies.  Fortunately, there are some Whole Health approaches, particularly in terms of Food and Drink, that can help to reduce symptoms.

Pathophysiology

Increased colonic pressure causes mucosal out-pouching.  It may be helpful to reduce this elevated pressure through:[1]

  • Regular evacuation
  • Eating a plant-based diet
  • Stress reduction
  • Calcium channel blockers. This group of medications reduces smooth muscle contraction, lowering luminal pressure, and they have been associated with fewer recurrences.

Factors associated with increased risk

  • Eating meat
  • Smoking
  • Obesity
  • Chronic steroid use
  • Taking opioids
  • Taking NSAIDS

Factors Associated with Reduced Risk

  • Vegetarian diets
  • Eating nuts and corn
  • Regular physical activity

Of note, fiber has not been found to reduce the risk.[4][5]  However, it is perhaps best to have your patients try to meet daily nutritional recommendations for fiber, given it has benefits for so many other conditions.  Furthermore, telling patients not to eat nuts and corn for fear of having those foods become entrapped in a “tic” is a myth, and does not hold true even after acute flares.[6]  As noted above, eating these foods is actually associated with reduced risk.

Reducing Risk of Recurrence

  • Don’t give long-term antibiotics prophylactically for diverticulitis. They generally have not been found beneficial except in possibly relieving pain and bloating during exacerbations.[6][7]
  • Hold off on jumping right to surgery for diverticular disease. Many people will not have a recurrence. In one study of 3,165 patients hospitalized for diverticulitis, only 13.3% had a recurrence after 9 years.
  • Consider mesalazine in those who have had a recurrence of diverticulitis. Reducing inflammation with this drug (but not NSAIDS, which can worsen risk) has been found beneficial when used cyclically for 10 days per month over 12 months. The dose is 400-800 mg twice daily, with the higher dose (800 mg twice daily) being more effective in one study.[8]
  • If a patient has diverticulitis and high blood pressure, consider a calcium channel blocker to reduce intraluminal pressure (and lower blood pressure as well).
  • Although fiber has not been found to reduce the recurrence of diverticulitis, it does help reduce constipation, which can aggravate this condition. Encourage 7-9 servings of vegetables and fruit daily and, if this is not possible, consider supplementing with a soluble fiber such as psyllium, 1 tbsp in 12 oz of water twice daily.

Author(s)

“Preventing Recurrent Diverticulitis” was written by David Rakel, MD and updated by David Lessens, MD, MPH (2014, updated 2020).

This Whole Health tool was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.

References

  1. Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid diverticulitis: a systematic review. J Am Med Assoc. 2014;311(3):287-297.
  2. Ellison DL. Acute Diverticulitis Management. Crit Care Nurs Clin North Am. 2018;30(1):67-74.
  3. You H, Sweeny A, Cooper ML, Von Papen M, Innes J. The management of diverticulitis: a review of the guidelines. Med J Aust. 2019;211(9):421-427.
  4. Carabotti M, Annibale B, Severi C, Lahner E. Role of fiber in symptomatic uncomplicated diverticular disease: a systematic review. Nutrients. 2017;9(2).
  5. Hupfeld L, Burcharth J, Pommergaard HC, Rosenberg J. Risk factors for recurrence after acute colonic diverticulitis: a systematic review. Int J Colorectal Dis. 2017;32(5):611-622.
  6. Dahl C, Crichton M, Jenkins J, et al. Evidence for dietary fibre modification in the recovery and prevention of reoccurrence of acute, uncomplicated diverticulitis: a systematic literature review. Nutrients. 2018;10(2).
  7. Lahner E, Bellisario C, Hassan C, Zullo A, Esposito G, Annibale B. Probiotics in the treatment of diverticular disease. A systematic review. J Gastrointestin Liver Dis. 2016;25(1):79-86.
  8. Comparato G, Fanigliulo L, Cavallaro LG, et al. Prevention of complications and symptomatic recurrences in diverticular disease with mesalazine: a 12-month follow-up. Dig Dis Sci. 2007;52(11):2934-2941.

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