Introduction

Colonic diverticulosis is defined as a protrusion of the mucosa and submucosa through a weak portion of the muscle layer [1]. Although the underlying mechanism of diverticulosis has not been fully elucidated, decreased stool volume due to a low-fiber diet, delayed colon transit, constipation, and increased intraluminal pressure due to overcontraction have been implicated [2-4].

Although the prevalence of colonic diverticulosis is lower in Asia than in Western countries, it has increased with an aging society and westernized food culture [5]. Diverticular disease is sometimes considered synonymous with diverticulosis; however, the exact definition of diverticular disease is a condition that combines clinically significant symptoms, including diverticulitis and diverticular bleeding [6-8]. In this review, we discuss the classification and unresolved issues associated with diverticular diseases in terms of diagnosis, treatment, and prevention.

Classification

Diverticulosis can be classified as asymptomatic or symptomatic. Symptomatic diverticulosis is similar to diverticular disease. Asymptomatic diverticulosis is usually detected incidentally during radiologic or colonoscopic evaluation [1]. According to a previous report, diverticulosis is more common in the left colon in Western countries, and not all colonic walls protrude (pseudodiverticulum) [1]. In contrast, in Asia, diverticulosis usually presents as a true diverticulum, which is more common in the right colon and does not increase with aging [1]. However, these differences decrease over time in Asians who move to Western countries, indicating the significant impact of diet and lifestyle [9].

A precise definition of the clinical significance of asymptomatic diverticulosis is lacking, making indications for treatment controversial [10]. Symptomatic diverticulosis or diverticular disease includes diverticulitis, diverticular bleeding, symptomatic uncomplicated diverticular disease (SUDD), and segmental colitis associated with diverticulosis (SCAD) (Fig. 1) [9].

1. Diverticulitis

Diverticulitis can be defined as acute or chronic inflammation of the diverticulum and is the most common complication (4%–15%) of diverticulosis [11,12]. Diverticulitis develops when fecaliths obstruct the sac owing to mucosal irritation, low-grade inflammation, and congestion [10]. Diverticulitis can be classified based on the presence or absence of complications [13]. Uncomplicated diverticulitis is an inflammation of the diverticulum and its surrounding wall, whereas complicated diverticulitis presents with an abscess, perforation, fistula, stricture, or obstruction. Diverticulitis has a prevalence of 12% to 15% [14,15].

Most cases of diverticulitis are acute episodes; however, approximately 5% to 10% of cases show prolonged symptoms. The typical symptoms of acute diverticulitis include localized abdominal pain (mostly in the left lower quadrant in Western countries and the right lower quadrant in Asia) [16,17].

2. Diverticular bleeding

Diverticular bleeding is one of the main causes of acute lower gastrointestinal bleeding. According to a previous study, approximately 30% to 65% of lower gastrointestinal bleeding cases are related to diverticula [18]. A bleeding incidence of 10% to 15% has been reported in patients with diverticulosis [7,8,19]. Bleeding is thought to develop from the herniated exposed vasa recta that protrudes over the dome of the diverticulum [1]. Diverticular bleeding is more common in the right-sided colon because the wall is thinner and the neck of the diverticulum is wider [20-22].

Diverticular bleeding is usually painless and is self-limiting in most cases [23]. Bleeding is brisk in some patients with hypotension and tachycardia, requiring resuscitation and transfusion.

Diagnosis can be confirmed by colonoscopy when there is a single diverticulum with obvious evidence of bleeding, such as active bleeding, exposed vessels, or adherent clots. However, the probability of detection is less than 15% to 20% [8,24].

3. Symptomatic uncomplicated diverticular disease

SUDD is suspected when patients complain of nonspecific abdominal pain with no evidence of inflammation in the diverticulum by endoscopy or radiology [1]. Pain is typically colicky but can be continuous and improves after defecation. Changes in bloating and bowel habits may also occur. Considering these symptoms, distinguishing SUDD from irritable bowel syndrome (IBS) can be challenging. A recent study reported a prevalence of up to 15% for SUDD in diverticulosis, with classifications including SUDD, IBS-like SUDD, and post-diverticulitis SUDD [25].

The suggested pathogenesis of SUDD includes visceral hypersensitivity, low-grade inflammation, changes in gut microbiota, and abnormal colonic motility following an episode of diverticulitis [26-30]. Due to their overlapping pathogeneses and clinical symptoms, the current treatments for SUDD and IBS are similar, including fiber intake and antibiotics such as rifaximin [31,32]. Mesalamine, probiotics, and antispasmodics can also be considered as treatment options, although their indications have not yet been established [31].

4. Segmental colitis associated with diverticulosis

SCAD is known as diverticula-associated colitis and is diagnosed when there is chronic inflammation in an area of colonic diverticulosis without involvement of the diverticular orifice. The estimated prevalence of SCAD in diverticulosis is 1% [33,34]. Various clinical symptoms, including bleeding, diarrhea, and abdominal pain, can occur simultaneously. Endoscopy can reveal erythema, friability, and erosion, and computed tomography (CT) can reveal inflammation around the diverticula. Typically, inflammation spares the rectum and ascending colon [34]. The evidence for treatment is limited; however, antibiotics such as ciprofloxacin and metronidazole with mesalamine or oral steroids can be considered [35,36].

Risk of diverticular disease associated with aspirin and nonsteroidal anti-inflammatory drugs

Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) directly injure the colonic mucosa and inhibit prostaglandin synthesis. They increase intestinal permeability and reduce barrier function. Therefore, diverticular disease develops due to the influx of gut microbiota and toxins into the colon [37,38]. In addition, these drugs can aggravate diverticular bleeding owing to mucosal ulceration and decreased platelet function [39].

The association between aspirin or NSAIDs and diverticular disease has been demonstrated in a longitudinal study [40]. This large prospective cohort study in the United States included 47,210 males from the Health Professionals Follow-up Study who worked in the medical field in 1986 and were aged 40 years to 75 years. Data on aspirin and NSAIDs use were evaluated every 2 years since 1986, and the history of diverticular disease was collected every 2 years since 1990. A total of 939 diverticulitis and 256 diverticular bleeding cases were reported during 22 years of follow-up. After adjusting for other risk factors of diverticular disease, participants who took aspirin at least two times per week showed a significantly higher risk of diverticulitis than those in the control group (hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.05–1.47), and the HR for diverticular bleeding was 1.70 (95% CI, 1.20–2.39). Another meta-analysis of 11 studies on NSAIDs indicated an association with diverticular perforation (odds ratio [OR], 3.4) and 12 studies indicated an association with diverticular bleeding (OR, 2.6) [41].

Management of colonic diverticulitis

1. Dietary restriction and bowel rest for colonic diverticulitis

Although many clinicians recommend diet restriction during the acute phase of diverticulitis, the evidence is scarce. Considering that food intake increases peristalsis and pressure on the intestine, a restricted diet could be beneficial. However, this is not always necessary in outpatient settings in the absence of fever or other severe symptoms. A clear diet can be attempted in these cases and advanced based on symptom improvement within 3 to 5 days [15,42].

2. Antibiotics in uncomplicated diverticulitis

Diet modification is the best management strategy for incidental asymptomatic diverticulosis, and fiber intake can reduce the risk of diverticular disease-associated hospitalization [43,44]. Mild cases of symptomatic uncomplicated acute diverticulitis can be treated with broad-spectrum antibiotics against anaerobic microorganisms in outpatient clinics for 7 to 10 days [45-48]. Regarding treatment duration, one study indicated no significant difference between the 4- and 7-day treatment courses [49].

Hospitalization with intravenous antibiotics and fluid treatment is required for patients with severe symptoms or for older adults. Approximately 75% of patients who are hospitalized with acute diverticulitis respond favorably to medical treatment [50,51]. Clinical guidelines recommend changing intravenous antibiotics to oral agents if patients show clinical improvement without fever for 24 to 48 hours and a decreased leukocyte count [52]. Antibiotics must target both aerobic and anaerobic microbes. The most used antibiotics in outpatient clinics are a combination of ciprofloxacin and metronidazole [53]. In patients who are hospitalized, a combination of intravenous ceftriaxone and metronidazole, piperacillin and tazobactam, or meropenem as a single agent, can be used for 7 to 10 days [54].

A recent multicenter randomized clinical trial of 623 patients with uncomplicated acute diverticulitis showed no significant difference in recurrence or complications for 1 year after the episode between patients treated with and without antibiotics [55]. A meta-analysis by Hjern et al. [56] also indicated no additional benefits of antibiotics for uncomplicated left-sided diverticulitis. Similarly, a recent meta-analysis revealed that conservative treatment without antibiotics reduced the number of hospitalization days in patients who were clinically stable with uncomplicated diverticulitis [57]. Considering the risks of antibiotic resistance, cost, and adverse events, more care should be taken regarding antibiotic treatment for uncomplicated diverticulitis based on these recent data. Therefore, recent practice guidelines recommend antibiotics for uncomplicated mild diverticulitis only in cases of American Society of Anesthesiologists class III or IV comorbidities, persistent symptoms longer than 5 days prior to presentation, and a C-reactive protein level of >14 mg/dL or a white blood cell level of >15,000 cells/L [15].

3. Indication for hospitalization and discharge criteria in diverticulitis

Patients with uncomplicated diverticulitis can be treated in an outpatient setting, unless they have significant comorbidities or are immunosuppressed [47,48]. According to a retrospective study, patients with mildly complicated diverticulitis (abscess <4 cm or pneumoperitoneum <2 cm) can also be safely treated in outpatient clinics with close follow-up [58]. However, another retrospective study revealed a 50% rehospitalization rate after discharge from the emergency department [59]. More studies on the indications for hospitalization in mildly complicated diverticulitis are needed.

Discharge can be considered when symptoms are well-controlled without complications and the patient tolerates diet, is immunocompetent, and has stable vital signs [15,60-62]. Postdischarge follow-ups are required, especially in patients who are discharged without antibiotic therapy.

Colonoscopy in diverticular disease

1. Colonoscopy after diverticulitis diagnosed by computed tomography

CT is the first and most widely used diagnostic modality because it is noninvasive and useful for evaluating inflammation around the diverticulum and detecting complications [63]. CT has an estimated sensitivity and specificity of 98% and 99%, respectively [64]. CT can be helpful in differentiating diverticulitis from other diseases such as colon cancer, appendicitis, epiploic appendagitis, ischemic colitis, and inflammatory bowel disease [64].

As CT can show the presence of a diverticulum with bowel wall thickening, pericolic infiltration, enhancement, abscess, obstruction, and lymph node enlargement in diverticulitis, differentiating diverticulitis from malignancy is sometimes difficult [65]. Therefore, colonoscopy is recommended to exclude the possibility of malignancy after an episode of diverticulitis, particularly in patients with no history of colonoscopy [66]. According to one systematic review evaluating the clinical utility of colonoscopy after acute diverticulitis diagnosed by abdominal CT, colonoscopy 4 to 8 weeks after a diverticulitis episode detected 15 cases of colon cancer and 38 cases of advanced adenoma [67].

As inflation with gas can result in colonic perforation, colonoscopy should be avoided during the acute phase. Therefore, colonoscopy is usually recommended at least 6 weeks after recovery from acute diverticulitis [68].

Urgent colonoscopy in diverticular bleeding

Although colonoscopy is a useful modality for diagnosing and treating colonic diverticular bleeding, it is challenging because the bleeding ceases spontaneously in 75% of cases [23]. After spontaneous hemostasis, identifying and treating the stigmata associated with a recent hemorrhage is difficult. Studies that indicated the effectiveness of colonoscopy within 24 hours of admission failed to show an improvement in the rebleeding rate within 30 days [69-71]. A recent multicenter randomized controlled study reported no significant difference in the stigmata of recent bleeding and rebleeding within 30 days between early (24 hours) and elective (>24 hours) colonoscopy. Another study showed that elective colonoscopy could be performed except in cases of positive extravasation on CT [72]. Another difficulty associated with early colonoscopy is bowel preparation. Bowel preparation is essential for visualizing lesions; however, it is time-consuming.

Although it did not show significant efficacy in improving the rebleeding rate, early colonoscopy with proper bowel preparation could help detect the bleeding focus, which is usually suggested in practice [42].

Indications of surgical treatment in diverticular disease

1. Diverticulitis

The old concept that the risk of complications increases after one or two recurrences has changed. Recent evidence has shown that the risk does not increase despite multiple recurrences [73]. Moreover, most complications develop during the first or second episode, except for fistulas. Based on these results, a personalized approach considering the number of recurrences, severity, and patient condition has been suggested [73]. Surgical treatment should be reserved for patients with peritonitis or perforation [73].

2. Diverticular bleeding

Although diverticular bleeding is the most common cause of hematochezia in patients who are older (≥60 years), only 10% to 15% of patients with diverticulosis experience bleeding, and 3% to 5% of these cases are severe [74-77]. More than 50% of diverticular bleeding cases stop spontaneously and only 4.6% require endoscopic intervention [78]. Surgery is rarely required in such cases. The indications for surgery include the requirement for transfusion of more than six units within 24 hours [79], recurrent hemorrhage that is refractory or not indicated for nonsurgical treatment, or hemodynamic instability [80]. The mortality rate of emergency surgery for uncontrolled bleeding is reportedly 10% to 20% [81,82].

Segmental resection should be considered only in confirmed bleeding foci, but the rebleeding rate is up to 14% [83]. Thus, a postoperative colonoscopy is needed to detect the bleeding focus and the presence of diverticulosis, and right or left colectomy should be performed. In cases of refractory bleeding from an undetectable focus, subtotal colectomy is required, with a high risk of complications and mortality [79].

High-fiber diet and various medications for prevention of diverticular disease

Traditionally, diverticulitis has been considered to develop due to obstruction of the diverticulum opening, fecal stasis, and bacterial overgrowth [84]. However, the concept of diverticular disease as a chronic inflammatory disease has recently emerged [85,86]. Microscopic low-grade inflammation around the diverticulum without evidence of gross inflammation, an association between the degree of inflammation and symptom severity, and increased proinflammatory cytokines such as tumor necrosis factor-α could indicate that chronic inflammation is critical in the development of diverticular disease [87]. In addition, changes in gut microbiota, visceral hypersensitivity, and abnormal bowel motility interact in a complex manner to cause diverticular disease [1]. Based on this understanding of pathogenesis, studies on the efficacy of 5-aminosalicylates (5-ASAs), rifaximin, and probiotics in preventing diverticulitis recurrence and improving chronic inflammation have been reported [88-90].

A high-fiber diet appears to reduce the long-term risk of diverticulitis recurrence [91,92], but a recent systematic literature review reported limited evidence [93]. Although the importance of dietary fiber has waned recently, it is still recommended for its potential preventive benefits [91]. It is reasonable to recommend a high-fiber diet because it reduces the risk of symptomatic diverticular disease, including diverticulitis and bleeding [44]. It also has favorable effects on various chronic diseases, such as cardiovascular disease, obesity, and diabetes [1].

Recently, other medications such as rifaximin, 5-ASAs, and probiotics have been suggested to prevent diverticulitis. Rifaximin (a nonabsorbable antibiotic) significantly reduced the symptoms of diverticulitis at 1 year [32]; however, a recent study failed to confirm the role of rifaximin in secondary prevention and its proper dosing [94].

In the case of mesalamine, there are conflicting data, with only one positive result compared with placebo [95-97]. A 2017 Cochrane review of seven randomized controlled trials found no significant differences in diverticulitis recurrence. However, the data quality was very low and significantly heterogeneous [98]. Although some studies have shown a tendency for improved symptoms and reduced recurrence [99], there has been insufficient evidence to recommend probiotics in the prevention of diverticulitis [100]. In addition to these medications for secondary prevention, general recommendations for the prevention of diverticular disease, especially diverticulitis, are summarized in Table 1, although the evidence is limited [101].

Conclusion

In addition to traditional concepts, chronic low-grade inflammation, alterations in the gut microbiota, visceral hypersensitivity, and abnormal intestinal motility have recently emerged as important factors in the pathogenesis of diverticular disease. Although guidelines based on recent clinical studies provide recommendations regarding the diagnosis, management, and prevention of diverticular diseases, controversies remain regarding dietary modifications, prophylactic medications, surgical indications, and the use of antibiotics for uncomplicated diverticulitis. Further studies are required to confirm these issues based on routine practice.

Article information

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

This study was supported by the 2022 Yeungnam University Research Grant.

Fig. 1.

Classification of diverticulosis and diverticular disease.

References

• 1. Wan D, Krisko T. Diverticulosis, diverticulitis, and diverticular bleeding. Clin Geriatr Med 2021;37:141–54.ArticlePubMed
• 2. Ma W, Nguyen LH, Song M, Jovani M, Liu PH, Cao Y, et al. Intake of dietary fiber, fruits, and vegetables and risk of diverticulitis. Am J Gastroenterol 2019;114:1531–8.ArticlePubMedPMC
• 3. Strate LL, Keeley BR, Cao Y, Wu K, Giovannucci EL, Chan AT. Western dietary pattern increases, and prudent dietary pattern decreases, risk of incident diverticulitis in a prospective cohort study. Gastroenterology 2017;152:1023–30.ArticlePubMedPMC
• 4. Cao Y, Strate LL, Keeley BR, Tam I, Wu K, Giovannucci EL, et al. Meat intake and risk of diverticulitis among men. Gut 2018;67:466–72.ArticlePubMedPMC
• 5. Song JH, Kim YS, Lee JH, Ok KS, Ryu SH, Lee JH, et al. Clinical characteristics of colonic diverticulosis in Korea: a prospective study. Korean J Intern Med 2010;25:140–6.ArticlePubMedPMCPDF
• 6. Shahedi K, Fuller G, Bolus R, Cohen E, Vu M, Shah R, et al. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol 2013;11:1609–13.ArticlePubMedPMC
• 7. Niikura R, Nagata N, Shimbo T, Aoki T, Yamada A, Hirata Y, et al. Natural history of bleeding risk in colonic diverticulosis patients: a long-term colonoscopy-based cohort study. Aliment Pharmacol Ther 2015;41:888–94.ArticlePubMed
• 8. Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000;342:78–82.ArticlePubMed
• 9. Zullo A, Gatta L, Vassallo R, Francesco V, Manta R, Monica F, et al. Paradigm shift: the Copernican revolution in diverticular disease. Ann Gastroenterol 2019;32:541–53.ArticlePubMedPMC
• 10. Touzios JG, Dozois EJ. Diverticulosis and acute diverticulitis. Gastroenterol Clin North Am 2009;38:513–25.ArticlePubMed
• 11. Rezapour M, Ali S, Stollman N. Diverticular disease: an update on pathogenesis and management. Gut Liver 2018;12:125–32.ArticlePubMedPMC
• 12. Bharucha AE, Parthasarathy G, Ditah I, Fletcher JG, Ewelukwa O, Pendlimari R, et al. Temporal trends in the incidence and natural history of diverticulitis: a population-based study. Am J Gastroenterol 2015;110:1589–96.ArticlePubMedPMCPDF
• 13. Eckmann JD, Shaukat A. Updates in the understanding and management of diverticular disease. Curr Opin Gastroenterol 2022;38:48–54.ArticlePubMed
• 14. Stollman N, Smalley W, Hirano I; AGA Institute Clinical Guidelines Committee. American Gastroenterological Association institute guideline on the management of acute diverticulitis. Gastroenterology 2015;149:1944–9.ArticlePubMed
• 15. Peery AF, Shaukat A, Strate LL. AGA clinical practice update on medical management of colonic diverticulitis: expert review. Gastroenterology 2021;160:906–11.ArticlePubMedPMC
• 16. Eberhardt F, Crichton M, Dahl C, Nucera R, Jenkins J, Marx W, et al. Role of dietary fibre in older adults with asymptomatic (AS) or symptomatic uncomplicated diverticular disease (SUDD): systematic review and meta-analysis. Maturitas 2019;130:57–67.ArticlePubMed
• 17. Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emerg Med Clin North Am 2016;34:559–74.ArticlePubMed
• 18. Peery AF, Crockett SD, Murphy CC, Lund JL, Dellon ES, Williams JL, et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018. Gastroenterology 2019;156:254–72.ArticlePubMedPMC
• 19. McGuire HH, Haynes BW. Massive hemorrhage for diverticulosis of the colon: guidelines for therapy based on bleeding patterns observed in fifty cases. Ann Surg 1972;175:847–55.ArticlePubMedPMC
• 20. Meyers MA, Alonso DR, Gray GF, Baer JW. Pathogenesis of bleeding colonic diverticulosis. Gastroenterology 1976;71:577–83.ArticlePubMed
• 21. Casarella WJ, Kanter IE, Seaman WB. Right-sided colonic diverticula as a cause of acute rectal hemorrhage. N Engl J Med 1972;286:450–3.ArticlePubMed
• 22. Wong SK, Ho YH, Leong AP, Seow-Choen F. Clinical behavior of complicated right-sided and left-sided diverticulosis. Dis Colon Rectum 1997;40:344–8.ArticlePubMed
• 23. McGuire HH. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg 1994;220:653–6.ArticlePubMedPMC
• 24. Smoot RL, Gostout CJ, Rajan E, Pardi DS, Schleck CD, Harmsen WS, et al. Is early colonoscopy after admission for acute diverticular bleeding needed? Am J Gastroenterol 2003;98:1996–9.ArticlePubMed
• 25. Tursi A, Elisei W, Franceschi M, Picchio M, Di Mario F, Brandimarte G. The prevalence of symptomatic uncomplicated diverticular disease could be lower than expected: a single-center colonoscopy-based cohort study. Eur J Gastroenterol Hepatol 2021;33:e478–83.ArticlePubMed
• 26. Bassotti G, Sietchiping-Nzepa F, De Roberto G, Chistolini F, Morelli A. Colonic regular contractile frequency patterns in irritable bowel syndrome: the 'spastic colon' revisited. Eur J Gastroenterol Hepatol 2004;16:613–7.ArticlePubMed
• 27. Bassotti G, Battaglia E, Bellone G, Dughera L, Fisogni S, Zambelli C, et al. Interstitial cells of Cajal, enteric nerves, and glial cells in colonic diverticular disease. J Clin Pathol 2005;58:973–7.ArticlePubMedPMC
• 28. Simpson J, Sundler F, Humes DJ, Jenkins D, Scholefield JH, Spiller RC. Post inflammatory damage to the enteric nervous system in diverticular disease and its relationship to symptoms. Neurogastroenterol Motil 2009;21:847–e58.ArticlePubMed
• 29. Barbaro MR, Cremon C, Fuschi D, Scaioli E, Veneziano A, Marasco G, et al. Nerve fiber overgrowth in patients with symptomatic diverticular disease. Neurogastroenterol Motil 2019;31:e13575.ArticlePubMedPDF
• 30. Kvasnovsky CL, Leong LE, Choo JM, Abell GC, Papagrigoriadis S, Bruce KD, et al. Clinical and symptom scores are significantly correlated with fecal microbiota features in patients with symptomatic uncomplicated diverticular disease: a pilot study. Eur J Gastroenterol Hepatol 2018;30:107–12.ArticlePubMed
• 31. Tursi A, Papa A, Danese S. Review article: the pathophysiology and medical management of diverticulosis and diverticular disease of the colon. Aliment Pharmacol Ther 2015;42:664–84.ArticlePubMed
• 32. Bianchi M, Festa V, Moretti A, Ciaco A, Mangone M, Tornatore V, et al. Meta-analysis: long-term therapy with rifaximin in the management of uncomplicated diverticular disease. Aliment Pharmacol Ther 2011;33:902–10.ArticlePubMed
• 33. Mann NS, Hoda KK. Segmental colitis associated with diverticulosis: systematic evaluation of 486 cases with meta-analysis. Hepatogastroenterology 2012;59:2119–21.PubMed
• 34. Tursi A, Elisei W, Brandimarte G, Giorgetti GM, Lecca PG, Di Cesare L, et al. The endoscopic spectrum of segmental colitis associated with diverticulosis. Colorectal Dis 2010;12:464–70.ArticlePubMed
• 35. Schembri J, Bonello J, Christodoulou DK, Katsanos KH, Ellul P. Segmental colitis associated with diverticulosis: is it the coexistence of colonic diverticulosis and inflammatory bowel disease? Ann Gastroenterol 2017;30:257–61.ArticlePubMedPMC
• 36. Rampton DS. Diverticular colitis: diagnosis and management. Colorectal Dis 2001;3:149–53.ArticlePubMed
• 37. Morris CR, Harvey IM, Stebbings WS, Speakman CT, Kennedy HJ, Hart AR. Epidemiology of perforated colonic diverticular disease. Postgrad Med J 2002;78:654–8.ArticlePubMedPMCPDF
• 38. Lanas A, Sopeña F. Nonsteroidal anti-inflammatory drugs and lower gastrointestinal complications. Gastroenterol Clin North Am 2009;38:333–52.ArticlePubMed
• 39. Foutch PG. Diverticular bleeding: are nonsteroidal anti-inflammatory drugs risk factors for hemorrhage and can colonoscopy predict outcome for patients? Am J Gastroenterol 1995;90:1779–84.PubMed
• 40. Strate LL, Liu YL, Huang ES, Giovannucci EL, Chan AT. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology 2011;140:1427–33.ArticlePubMed
• 41. Kvasnovsky CL, Papagrigoriadis S, Bjarnason I. Increased diverticular complications with nonsteriodal anti-inflammatory drugs and other medications: a systematic review and meta-analysis. Colorectal Dis 2014;16:O189–96.ArticlePubMed
• 42. Nagata N, Ishii N, Manabe N, Tomizawa K, Urita Y, Funabiki T, et al. Guidelines for colonic diverticular bleeding and colonic diverticulitis: Japan Gastroenterological Association. Digestion 2019;99(Suppl 1):1–26.ArticlePubMedPDF
• 43. Crowe FL, Appleby PN, Allen NE, Key TJ. 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.ArticlePubMedPMC
• 44. Crowe FL, Balkwill A, Cairns BJ, Appleby PN, Green J, Reeves GK, et al. Source of dietary fibre and diverticular disease incidence: a prospective study of UK women. Gut 2014;63:1450–6.ArticlePubMed
• 45. Sánchez-Velázquez P, Grande L, Pera M. Outpatient treatment of uncomplicated diverticulitis: a systematic review. Eur J Gastroenterol Hepatol 2016;28:622–7.ArticlePubMed
• 46. Balasubramanian I, Fleming C, Mohan HM, Schmidt K, Haglind E, Winter DC. Out-patient management of mild or uncomplicated diverticulitis: a systematic review. Dig Surg 2017;34:151–60.ArticlePubMedPDF
• 47. van Dijk ST, Bos K, de Boer MG, Draaisma WA, van Enst WA, Felt RJ, et al. A systematic review and meta-analysis of outpatient treatment for acute diverticulitis. Int J Colorectal Dis 2018;33:505–12.ArticlePubMedPMCPDF
• 48. Cirocchi R, Randolph JJ, Binda GA, Gioia S, Henry BM, Tomaszewski KA, et al. Is the outpatient management of acute diverticulitis safe and effective? A systematic review and meta-analysis. Tech Coloproctol 2019;23:87–100.ArticlePubMedPDF
• 49. Schug-Pass C, Geers P, Hügel O, Lippert H, Köckerling F. Prospective randomized trial comparing short-term antibiotic therapy versus standard therapy for acute uncomplicated sigmoid diverticulitis. Int J Colorectal Dis 2010;25:751–9.ArticlePubMedPDF
• 50. Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med 2007;357:2057–66.ArticlePubMed
• 51. Young-Fadok TM. Diverticulitis. N Engl J Med 2018;379:1635–42.ArticlePubMed
• 52. World Gastroenterology Organisation (WGO). WGO practice guideline [Internet]. Milwaukee: WGO; 2006 [updated 2007; cited 2024 May 17]. https://www.worldgastroenterology.org/guidelines/diverticular-disease/diverticular-disease-english.
• 53. Dichman ML, Rosenstock SJ, Shabanzadeh DM. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev 2022;6:CD009092.ArticlePubMedPMC
• 54. Weizman AV, Nguyen GC. Diverticular disease: epidemiology and management. Can J Gastroenterol 2011;25:385–9.ArticlePubMedPMCPDF
• 55. Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012;99:532–9.ArticlePubMed
• 56. Hjern F, Josephson T, Altman D, Holmström B, Mellgren A, Pollack J, et al. Conservative treatment of acute colonic diverticulitis: are antibiotics always mandatory? Scand J Gastroenterol 2007;42:41–7.ArticlePubMed
• 57. Mohamedahmed AY, Zaman S, Das N, Kakaniaris G, Vakis S, Eccersley J, et al. Systematic review and meta-analysis of the management of acute uncomplicated diverticulitis: time to change traditional practice. Int J Colorectal Dis 2024;39:47.ArticlePubMedPMCPDF
• 58. Joliat GR, Emery J, Demartines N, Hübner M, Yersin B, Hahnloser D. Antibiotic treatment for uncomplicated and mild complicated diverticulitis: outpatient treatment for everyone. Int J Colorectal Dis 2017;32:1313–9.ArticlePubMedPDF
• 59. Sirany AE, Gaertner WB, Madoff RD, Kwaan MR. Diverticulitis diagnosed in the emergency room: is it safe to discharge home? J Am Coll Surg 2017;225:21–5.ArticlePubMed
• 60. Hall J, Hardiman K, Lee S, Lightner A, Stocchi L, Paquette IM, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum 2020;63:728–47.ArticlePubMed
• 61. Qaseem A, Etxeandia-Ikobaltzeta I, Lin JS, Fitterman N, Shamliyan T, Wilt TJ, et al. Diagnosis and management of acute left-sided colonic diverticulitis: a clinical guideline from the American College of Physicians. Ann Intern Med 2022;175:399–415.ArticlePubMed
• 62. Sartelli M, Catena F, Ansaloni L, Coccolini F, Griffiths EA, Abu-Zidan FM, et al. WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting. World J Emerg Surg 2016;11:37.PubMedPMC
• 63. Birnbaum BA, Balthazar EJ. CT of appendicitis and diverticulitis. Radiol Clin North Am 1994;32:885–98.PubMed
• 64. Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, et al. Diverticulitis: an update from the age old paradigm. Curr Probl Surg 2020;57:100862.ArticlePubMedPMC
• 65. Shen SH, Chen JD, Tiu CM, Chou YH, Chiang JH, Chang CY, et al. Differentiating colonic diverticulitis from colon cancer: the value of computed tomography in the emergency setting. J Chin Med Assoc 2005;68:411–8.ArticlePubMed
• 66. Hale WB; National Diverticulitis Study Group. Colonoscopy in the diagnosis and management of diverticular disease. J Clin Gastroenterol 2008;42:1142–4.ArticlePubMed
• 67. Daniels L, Unlü C, de Wijkerslooth TR, Dekker E, Boermeester MA. Routine colonoscopy after left-sided acute uncomplicated diverticulitis: a systematic review. Gastrointest Endosc 2014;79:378–89.ArticlePubMed
• 68. Almy TP, Howell DA. Medical progress. Diverticular disease of the colon. N Engl J Med 1980;302:324–31.ArticlePubMed
• 69. Kouanda AM, Somsouk M, Sewell JL, Day LW. Urgent colonoscopy in patients with lower GI bleeding: a systematic review and meta-analysis. Gastrointest Endosc 2017;86:107–17.ArticlePubMed
• 70. Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol 2010;105:2636–41.ArticlePubMedPDF
• 71. Green BT, Rockey DC, Portwood G, Tarnasky PR, Guarisco S, Branch MS, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol 2005;100:2395–402.ArticlePubMed
• 72. Ochi M, Kamoshida T, Hamano Y, Ohkawara A, Ohkawara H, Kakinoki N, et al. Early colonoscopy and urgent contrast enhanced computed tomography for colonic diverticular bleeding reduces risk of rebleeding. World J Clin Cases 2021;9:2446–57.ArticlePubMedPMC
• 73. Rafferty J, Shellito P, Hyman NH, Buie WD; Standards Committee of American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006;49:939–44.ArticlePubMed
• 74. Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 1988;95:1569–74.ArticlePubMed
• 75. Niikura R, Nagata N, Yamada A, Akiyama J, Shimbo T, Uemura N. Recurrence of colonic diverticular bleeding and associated risk factors. Colorectal Dis 2012;14:302–5.ArticlePubMed
• 76. Okamoto T, Watabe H, Yamada A, Hirata Y, Yoshida H, Koike K. The association between arteriosclerosis related diseases and diverticular bleeding. Int J Colorectal Dis 2012;27:1161–6.ArticlePubMedPDF
• 77. Nishikawa H, Maruo T, Tsumura T, Sekikawa A, Kanesaka T, Osaki Y. Risk factors associated with recurrent hemorrhage after the initial improvement of colonic diverticular bleeding. Acta Gastroenterol Belg 2013;76:20–4.PubMed
• 78. Ron-Tal Fisher O, Gralnek IM, Eisen GM, Williams JL, Holub JL. Endoscopic hemostasis is rarely used for hematochezia: a population-based study from the Clinical Outcomes Research Initiative National Endoscopic Database. Gastrointest Endosc 2014;79:317–25.ArticlePubMedPMC
• 79. Hall J, Hammerich K, Roberts P. New paradigms in the management of diverticular disease. Curr Probl Surg 2010;47:680–735.ArticlePubMed
• 80. Wilkins T, Baird C, Pearson AN, Schade RR. Diverticular bleeding. Am Fam Physician 2009;80:977–83.PubMed
• 81. Chen CY, Wu CC, Jao SW, Pai L, Hsiao CW. Colonic diverticular bleeding with comorbid diseases may need elective colectomy. J Gastrointest Surg 2009;13:516–20.ArticlePubMedPDF
• 82. Britt LG, Warren L, Moore OF. Selective management of lower gastrointestinal bleeding. Am Surg 1983;49:121–5.PubMed
• 83. Parkes BM, Obeid FN, Sorensen VJ, Horst HM, Fath JJ. The management of massive lower gastrointestinal bleeding. Am Surg 1993;59:676–8.PubMed
• 84. Tursi A, Scarpignato C, Strate LL, Lanas A, Kruis W, Lahat A, et al. Colonic diverticular disease. Nat Rev Dis Primers 2020;6:20.ArticlePubMedPMCPDF
• 85. Lahat A, Necula D, Yavzori M, Picard O, Halperin S, Eliakim R, et al. Prolonged recurrent abdominal pain is associated with ongoing underlying mucosal inflammation in patients who had an episode of acute complicated diverticulitis. J Clin Gastroenterol 2019;53:e178–85.ArticlePubMed
• 86. Tursi A, Elisei W, Giorgetti GM, Inchingolo CD, Nenna R, Picchio M, et al. Detection of endoscopic and histological inflammation after an attack of colonic diverticulitis is associated with higher diverticulitis recurrence. J Gastrointestin Liver Dis 2013;22:13–9.PubMed
• 87. Humes DJ, Simpson J, Smith J, Sutton P, Zaitoun A, Bush D, et al. Visceral hypersensitivity in symptomatic diverticular disease and the role of neuropeptides and low grade inflammation. Neurogastroenterol Motil 2012;24:318–e163.ArticlePubMed
• 88. Barbara G, Cremon C, Barbaro MR, Bellacosa L, Stanghellini V. Treatment of diverticular disease with aminosalicylates: the evidence. J Clin Gastroenterol 2016;50(Suppl 1):S60–3.ArticlePubMed
• 89. Scarpignato C, Bertelé A, Tursi A. Probiotics for the treatment of symptomatic uncomplicated diverticular disease: rationale and current evidence. J Clin Gastroenterol 2016;50(Suppl 1):S70–3.ArticlePubMed
• 90. Stallinger S, Eller N, Högenauer C. Non-interventional study evaluating efficacy and tolerability of rifaximin for treatment of uncomplicated diverticular disease. Wien Klin Wochenschr 2014;126:9–14.ArticlePubMedPDF
• 91. de Korte N, Kuyvenhoven JP, van der Peet DL, Felt-Bersma RJ, Cuesta MA, Stockmann HB. Mild colonic diverticulitis can be treated without antibiotics. A case-control study. Colorectal Dis 2012;14:325–30.ArticlePubMed
• 92. Stollman NH, Raskin JB; Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Diagnosis and management of diverticular disease of the colon in adults. Am J Gastroenterol 1999;94:3110–21.ArticlePubMed
• 93. Dahl C, Crichton M, Jenkins J, Nucera R, Mahoney S, Marx W, et al. Evidence for dietary fibre modification in the recovery and prevention of reoccurrence of acute, uncomplicated diverticulitis: a systematic literature review. Nutrients 2018;10:137.ArticlePubMedPMC
• 94. Moniuszko A, Rydzewska G. The effect of cyclic rifaximin therapy on symptoms of diverticular disease from the perspective of the gastroenterology outpatient clinic: a "real-life" study. Prz Gastroenterol 2017;12:145–51.ArticlePubMedPMC
• 95. Khan RM, Ali B, Hajibandeh S, Hajibandeh S. Effect of mesalazine on recurrence of diverticulitis in patients with symptomatic uncomplicated diverticular disease: a meta-analysis with trial sequential analysis of randomized controlled trials. Colorectal Dis 2018;20:469–78.ArticlePubMedPDF
• 96. Iannone A, Ruospo M, Wong G, Barone M, Principi M, Di Leo A, et al. Mesalazine for people with diverticular disease: a systematic review of randomized controlled trials. Can J Gastroenterol Hepatol 2018;2018:5437135.ArticlePubMedPMCPDF
• 97. Picchio M, Elisei W, Brandimarte G, Di Mario F, Malfertheiner P, Scarpignato C, 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):S64–9.ArticlePubMed
• 98. Carter F, Alsayb M, Marshall JK, Yuan Y. Mesalamine (5-ASA) for the prevention of recurrent diverticulitis. Cochrane Database Syst Rev 2017;10:CD009839.ArticlePubMedPMC
• 99. Banasiewicz T, Francuzik W, Bobkiewicz A, Krokowicz Ł, Borejsza-Wysocki M, Paszkowski J, et al. The influence of rifaximin on diverticulitis rate and quality of life in patients with diverticulosis. Pol Przegl Chir 2017;89:22–31.ArticlePubMedPDF
• 100. 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;25:79–86.ArticlePubMedPDF
• 101. Böhm SK, Kruis W. Lifestyle and other risk factors for diverticulitis. Minerva Gastroenterol Dietol 2017;63:110–8.PubMed

Figure & Data

References

Citations

Citations to this article as recorded by