Diverticular Disease: Reconsidering Conventional Wisdom

  • Anne F. Peery
    Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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  • Robert S. Sandler
    Reprint requests Address requests for reprints to: Robert S. Sandler, MD, MPH, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, CB#7555, Chapel Hill, North Carolina 27599-7555. fax: (919) 966-9185.
    Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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      Colonic diverticula are common in developed countries and complications of colonic diverticulosis are responsible for a significant burden of disease. Several recent publications have called into question long-held beliefs about diverticular disease. Contrary to conventional wisdom, studies have not shown that a high-fiber diet protects against asymptomatic diverticulosis. The risk of developing diverticulitis among individuals with diverticulosis is lower than the 10% to 25% proportion that commonly is quoted, and may be as low as 1% over 11 years. Nuts and seeds do not increase the risk of diverticulitis or diverticular bleeding. It is unclear whether diverticulosis, absent diverticulitis, or overt colitis is responsible for chronic gastrointestinal symptoms or worse quality of life. The role of antibiotics in acute diverticulitis has been challenged by a large randomized trial that showed no benefit in selected patients. The decision to perform elective surgery should be made on a case-by-case basis and not routinely after a second episode of diverticulitis, when there has been a complication, or in young people. A colonoscopy should be performed to exclude colon cancer after an attack of acute diverticulitis but may not alter outcomes among individuals who have had a colonoscopy before the attack. Given these surprising findings, it is time to reconsider conventional wisdom about diverticular disease.


      Abbreviation used in this paper:

      IBS (irritable bowel syndrome)
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        • Welch C.E.
        • Allen A.W.
        • Donaldson G.A.
        An appraisal of resection of the colon for diverticulitis of the sigmoid.
        Ann Surg. 1953; 138: 332-343
        • Everhart J.E.
        • Ruhl C.E.
        Burden of digestive diseases in the United States part II: lower gastrointestinal diseases.
        Gastroenterology. 2009; 136: 741-754
        • Peery A.F.
        • Dellon E.S.
        • Lund J.
        • et al.
        Burden of gastrointestinal disease in the United States: 2012 update.
        Gastroenterology. 2012; 143: 1179-1187
        • Masoomi H.
        • Buchberg B.S.
        • Magno C.
        • et al.
        Trends in diverticulitis management in the United States from 2002 to 2007.
        Arch Surg. 2011; 146: 400-406
        • Slack W.W.
        The anatomy, pathology, and some clinical features of divericulitis of the colon.
        Br J Surg. 1962; 50: 185-190
        • Hughes L.E.
        Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis.
        Gut. 1969; 10: 336-344
        • Hughes L.E.
        Postmortem survey of diverticular disease of the colon. II. The muscular abnormality of the sigmoid colon.
        Gut. 1969; 10: 344-351
        • Stollman N.H.
        • Raskin J.B.
        Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology.
        Am J Gastroenterol. 1999; 94: 3110-3121
        • Strate L.L.
        • Modi R.
        • Cohen E.
        • et al.
        Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.
        Am J Gastroenterol. 2012; 107: 1486-1493
        • Jacobs D.O.
        Clinical practice. Diverticulitis.
        N Engl J Med. 2007; 357: 2057-2066
        • Painter N.S.
        Diverticular disease of the colon–a disease of the century.
        Lancet. 1969; 2: 586-588
        • Painter N.S.
        • Burkitt D.P.
        Diverticular disease of the colon: a deficiency disease of Western civilization.
        Br Med J. 1971; 2: 450-454
        • Painter N.S.
        • Truelove S.C.
        • Ardran G.M.
        • et al.
        Segmentation and the localization of intraluminal pressures in the human colon, with special reference to the pathogenesis of colonic diverticula.
        Gastroenterology. 1965; 49: 169-177
        • 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
        • Parks T.G.
        • Connell A.M.
        Motility studies in diverticular disease of the colon.
        Gut. 1969; 10: 534-542
        • Weinreich J.
        • Andersen D.
        Intraluminal pressure in the sigmoid colon. II. Patients with sigmoid diverticula and related conditions.
        Scand J Gastroenterol. 1976; 11: 581-586
        • Weinreich J.
        • Moller S.H.
        • Andersen D.
        Colonic haustral pattern in relation to pressure activity and presence of diverticula.
        Scand J Gastroenterol. 1977; 12: 857-864
        • Leandro P.A.
        • Cecconello I.
        • Habr-Gama A.
        • et al.
        Gastrointestinal motility in normal subjects and patients with diverticulosis of the colon.
        Arq Gastroenterol. 1984; 21: 157-163
        • Viebig R.G.
        • Pontes J.F.
        • Michelsohn N.H.
        Electromanometry of the rectosigmoid in colonic diverticulosis.
        Arq Gastroenterol. 1994; 31: 135-144
        • Burkitt D.P.
        • Walker A.R.
        • Painter N.S.
        Effect of dietary fibre on stools and the transit-times, and its role in the causation of disease.
        Lancet. 1972; 2: 1408-1412
        • Manousos O.N.
        • Truelove S.C.
        • Lumsden K.
        Transit times of food in patients with diverticulosis or irritable colon syndrome and normal subjects.
        Br Med J. 1967; 3: 760-762
        • Kirwan W.O.
        • Smith A.N.
        Colonic propulsion in diverticular disease, idiopathic constipation, and the irritable colon syndrome.
        Scand J Gastroenterol. 1977; 12: 331-335
        • Peery A.F.
        • Barrett P.R.
        • Park D.
        • et al.
        A high-fiber diet does not protect against asymptomatic diverticulosis.
        Gastroenterology. 2012; 142: 266-272
        • Strate L.L.
        Diverticulosis and dietary fiber: rethinking the relationship.
        Gastroenterology. 2012; 142: 205-207
        • Song J.H.
        • Kim Y.S.
        • Lee J.H.
        • et al.
        Clinical characteristics of colonic diverticulosis in Korea: a prospective study.
        Korean J Intern Med. 2010; 25: 140-146
        • Lin O.S.
        • Soon M.S.
        • Wu S.S.
        • et al.
        Dietary habits and right-sided colonic diverticulosis.
        Dis Colon Rectum. 2000; 43: 1412-1418
        • Crowe F.L.
        • Appleby P.N.
        • Allen N.E.
        • 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
        • Aldoori W.H.
        • Giovannucci E.L.
        • Rockett H.R.
        • et al.
        A prospective study of dietary fiber types and symptomatic diverticular disease in men.
        J Nutr. 1998; 128: 714-719
        • Anderson J.W.
        • Baird P.
        • Davis Jr., R.H.
        • et al.
        Health benefits of dietary fiber.
        Nutr Rev. 2009; 67: 188-205
        • Aune D.
        • Chan D.S.
        • Lau R.
        • et al.
        Dietary fibre, whole grains, and risk of colorectal cancer: systematic review and dose-response meta-analysis of prospective studies.
        BMJ. 2011; 343: d6617
        • Stollman N.
        • Raskin J.B.
        Diverticular disease of the colon.
        Lancet. 2004; 363: 631-639
        • Parks T.G.
        Natural history of diverticular disease of the colon.
        Clin Gastroenterol. 1975; 4: 53-69
        • Pemberton J.D.
        • Black B.M.
        • Maino C.R.
        Progress in the surgical management of diverticulitis of the sigmoid colon.
        Surg Gynecol Obstet. 1947; 85: 523-534
        • Horner J.L.
        Natural history of diverticulosis of the colon.
        Am J Dig Dis. 1958; 3: 343-350
        • Boles Jr., R.S.
        • Jordan S.M.
        The clinical significance of diverticulosis.
        Gastroenterology. 1958; 35: 579-582
        • Shahedi K.F.G.
        • Bolus R.
        • et al.
        Progression from incidental diverticulosis to acute diverticulitis.
        Gastroenterology. 2012; 142: S144
        • Salzman H.
        • Lillie D.
        Diverticular disease: diagnosis and treatment.
        Am Fam Physician. 2005; 72: 1229-1234
        • Strate L.L.
        • Liu Y.L.
        • Syngal S.
        • et al.
        Nut, corn, and popcorn consumption and the incidence of diverticular disease.
        JAMA. 2008; 300: 907-914
        • Eglinton T.
        • Nguyen T.
        • Raniga S.
        • et al.
        Patterns of recurrence in patients with acute diverticulitis.
        Br J Surg. 2010; 97: 952-957
        • Comparato G.
        • Fanigliulo L.
        • Aragona G.
        • et al.
        Quality of life in uncomplicated symptomatic diverticular disease: is it another good reason for treatment?.
        Dig Dis. 2007; 25: 252-259
        • Humes D.J.
        • Simpson J.
        • Smith J.
        • et al.
        Visceral hypersensitivity in symptomatic diverticular disease and the role of neuropeptides and low grade inflammation.
        Neurogastroenterol Motil. 2012; 24 (318–e163)
        • Kang J.Y.
        • Firwana B.
        • Green A.E.
        • et al.
        Uncomplicated diverticular disease is not a common cause of colonic symptoms.
        Aliment Pharmacol Ther. 2011; 33: 487-494
        • Jung H.K.
        • Choung R.S.
        • Locke 3rd, G.R.
        • et al.
        Diarrhea-predominant irritable bowel syndrome is associated with diverticular disease: a population-based study.
        Am J Gastroenterol. 2010; 105: 652-661
        • Chabok A.
        • Pahlman L.
        • Hjern F.
        • et al.
        Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis.
        Br J Surg. 2012; 99: 532-539
        • Andersen J.C.
        • Bundgaard L.
        • Elbrond H.
        • et al.
        Danish national guidelines for treatment of diverticular disease.
        Dan Med J. 2012; 59: C4453
        • Westwood D.A.
        • Eglinton T.W.
        Antibiotics may not improve short-term or long-term outcomes in acute uncomplicated diverticulitis.
        Evid Based Med. 2013; 18: 32-33
        • Gatta L.
        • Vakil N.
        • Vaira D.
        • et al.
        Efficacy of 5-ASA in the treatment of colonic diverticular disease.
        J Clin Gastroenterol. 2010; 44: 113-119
        • Lamps L.W.
        • Knapple W.L.
        Diverticular disease-associated segmental colitis.
        Clin Gastroenterol Hepatol. 2007; 5: 27-31
        • Tursi A.
        • Elisei W.
        • Giorgetti G.M.
        • et al.
        Inflammatory manifestations at colonoscopy in patients with colonic diverticular disease.
        Aliment Pharmacol Ther. 2011; 33: 358-365
        • Broderick-Villa G.
        • Burchette R.J.
        • Collins J.C.
        • et al.
        Hospitalization for acute diverticulitis does not mandate routine elective colectomy.
        Arch Surg. 2005; 140 (discussion 81–83): 576-581
        • Anaya D.A.
        • Flum D.R.
        Risk of emergency colectomy and colostomy in patients with diverticular disease.
        Arch Surg. 2005; 140: 681-685
        • Janes S.
        • Meagher A.
        • Frizelle F.A.
        Elective surgery after acute diverticulitis.
        Br J Surg. 2005; 92: 133-142
        • Rafferty J.
        • Shellito P.
        • Hyman N.H.
        • et al.
        Practice parameters for sigmoid diverticulitis.
        Dis Colon Rectum. 2006; 49: 939-944
        • Freischlag J.
        • Bennion R.S.
        • Thompson Jr., J.E.
        Complications of diverticular disease of the colon in young people.
        Dis Colon Rectum. 1986; 29: 639-643
        • Chautems R.C.
        • Ambrosetti P.
        • Ludwig A.
        • et al.
        Long-term follow-up after first acute episode of sigmoid diverticulitis: is surgery mandatory?: a prospective study of 118 patients.
        Dis Colon Rectum. 2002; 45: 962-966
        • Reisman Y.
        • Ziv Y.
        • Kravrovitc D.
        • et al.
        Diverticulitis: the effect of age and location on the course of disease.
        Int J Colorectal Dis. 1999; 14: 250-254
        • Spivak H.
        • Weinrauch S.
        • Harvey J.C.
        • et al.
        Acute colonic diverticulitis in the young.
        Dis Colon Rectum. 1997; 40: 570-574
        • Konvolinka C.W.
        Acute diverticulitis under age forty.
        Am J Surg. 1994; 167: 562-565
        • Eusebio E.B.
        • Eisenberg M.M.
        Natural history of diverticular disease of the colon in young patients.
        Am J Surg. 1973; 125: 308-311
        • Ambrosetti P.
        • Robert J.H.
        • Witzig J.A.
        • et al.
        Acute left colonic diverticulitis in young patients.
        J Am Coll Surg. 1994; 179: 156-160
        • Ouriel K.
        • Schwartz S.I.
        Diverticular disease in the young patient.
        Surg Gynecol Obstet. 1983; 156: 1-5
        • McConnell E.J.
        • Tessier D.J.
        • Wolff B.G.
        Population-based incidence of complicated diverticular disease of the sigmoid colon based on gender and age.
        Dis Colon Rectum. 2003; 46: 1110-1114
        • Granlund J.
        • Svensson T.
        • Granath F.
        • et al.
        Diverticular disease and the risk of colon cancer—a population-based case-control study.
        Aliment Pharmacol Ther. 2011; 34: 675-681
        • Lau K.C.
        • Spilsbury K.
        • Farooque Y.
        • et al.
        Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded?.
        Dis Colon Rectum. 2011; 54: 1265-1270