New Approaches to Treating Diverticular Disease

San Diego—Recent research has indicated healthcare professionals should consider new approaches when treating diverticular disease, which affects the colon and has no known cause. Primarily, the disease affects older adults, however, the incidence in middle-age adults is increasing.

Common treatment options such as increasing the intake of dietary fiber, decreasing the intake of dietary fat, and increasing exercise are still effective in most cases. Patients with more serious disease typically take antibiotics or undergo surgery.

Still, Robin Spiller, MD, professor of gastroenterology at the University of Nottingham in the United Kingdom, said there is a “paradigm shift occurring” in understanding the disease.

During DDW, Dr. Spiller and other speakers presented an overview of the disease and highlighted some advances during a satellite symposium titled “The Modern Management of Diverticular Disease.”

Most people with diverticular disease never have symptoms and are pain free, according to Dr. Spiller. In fact, statistics show only 10% to 15% suffer from recurrent pain. Those who suffer from pain are characterized as experiencing acute inflammation (diverticulitis) or chronic pain associated with visceral hypersensitivity but without acute inflammation (referred to as irritable bowel syndrome-like).

Dr. Spiller cited a survey from Nottingham of 378 patients with diverticular disease that found 36% had recurrent abdominal pain. The most common symptoms were bloating, loose stool, hard stool, urgency, straining, and incontinence. She said other studies have determined that patients who experienced attacks of prolonged pain lasting >24 hours were 2 times more likely to have recurrent daily pain.

Meanwhile, a study found the following risk factors were significantly associated with developing recurrent pain: acute diverticulitis (P=.01) and anxiety score >7 on the Hospital Anxiety and Depression Scale (P=.03). Acute diverticulitis can lead to inflammatory damage to enteric nerves, altered neuropeptides, and an enhanced afferent response to physiological stimuli.

Dr. Spiller said acute diverticulitis and psychological factors play a role in predicting if patients with diverticular disease will experience pain. When determining the best way to treat the pain, she suggested that healthcare professionals should consider peripheral and central abnormalities. She also said targeted therapies aimed at different approaches for certain patients may be effective.

Neil Stollman, MD, chairman of the department of medicine at Alta Bates Summit Medical Center in Oakland, California, said diverticular disease is typically referred to as “staid” and “mundane.” Dr. Stollman said 15% to 20% of patients with diverticular disease would become symptomatic.

Dr. Stollman said patients with asymptomatic disease should not receive treatment, but should be educated and encouraged to consume a diet of more fiber and less fat and increase exercise. Lack of fiber in one’s diet is common and is associated with diverticulosis, according to Dr. Stollman. The recommended daily intake of fiber in the United States is 21 to 26 grams for women and 31 to 38 grams for men. However, the average fiber intake in the Western hemisphere is 15 grams per day.

Still, there are not a lot of empirical data supporting the belief that benefits associated with fiber help improve symptoms, according to Dr. Stollman. Recent, larger cohort studies have found that an increase in fiber leads to a decrease in symptoms.

Patients with symptomatic uncomplicated disease are characterized as having lower abdominal pain, bloating, constipation, diarrhea, and tenderness. Depending on their symptoms, they should receive education or be treated with antibiotics, according to Dr. Stollman.

Patients with symptomatic complicated disease have acute diverticulitis, abscess, fistula, or bowel obstruction. They are advised to take antibiotics and possibly be hospitalized if symptoms persist.

Although antibiotics are commonly prescribed to treat acute diverticulitis, Dr. Stollman said the data are “mixed.” In fact, a randomized controlled trial of 623 Swedish patients found there was no statistically significant difference in abscess, perforation, or recurrent diverticulitis when comparing patients who took antibiotics for ≥7 days with those who did not take antibiotics.

Common oral antibiotics include quinolone/metronidazole, trimethoprim-sulfamethoxazole/metronidazole, or amoxicillin/clavulinic acid. Common intravenous medications include aminoglycoside/aztreonam/third generation cephalosporin plus metronidazole/clindamycin or single agents such as unasyn, timentin, and cefoxitin.

Dr. Stollman said patients with recurrent disease should consider elective surgery, while those with perforation or peritonitis should undergo emergency surgery. Dr. Stollman said perforation or peritonitis is “extremely rare.”

The American Society of Colon and Rectal Surgeons recommends taking an individualized approach when considering surgery and notes that “the number of attacks of uncomplicated diverticulitis is not necessarily an overriding factor in defining the appropriateness of surgery.” Dr. Stollman said data show there is no increased risk of complications when delaying surgery.

It is difficult to estimate the incidence of diverticular disease, according to Dr. Stollman, because the majority of patients remain asymptomatic. However, there are geographic differences. The disease is rare in rural Africa and Asia, but is more common in the United States, Europe, and Australia.

In the United States, an estimated 65% of people with diverticular disease are >85 years of age and 95% are ≥60 years of age. However, hospitalization rates for the disease from 1998 through 2005 increased faster in people <45 years of age compared with older people.

In 2004, diverticular disease was the fifth most common gastrointestinal cause for ambulatory care visits, and Dr. Stollman said ambulatory visits and hospitalizations are rising.

“[Diverticular disease] is increasingly problematic [in the United States], for sure,” Dr. Stollman said. “There is no question this is a burdensome disease.”

Martin H. Floch, MD, clinical professor of medicine at Yale University, said ≥70% of patients respond to medical treatment to resolve a first attack of diverticulitis, although approximately 33% will experience recurrent diverticulitis, typically within a year of the first episode. Studies have shown the 5-year recurrence rate is between 19% and 54%.

Dr. Floch discussed some new approaches to treating the disease, including nonabsorbable antibiotics, anti-inflammatory agents, and probiotics. For example, cyclic administration of rifaximin (a nonabsorbable antibiotic) has been found to be effective in treating symptomatic uncomplicated disease.

Other trials have determined that mesalamine significantly improves symptoms such as urgency, tenesmus, diarrhea, and constipation in patients with diverticulitis, although a large study found mesalamine did not prevent the recurrence of diverticulitis.

In respect to probiotics, Dr. Floch said there have been no placebo-controlled trials and “it is too small a literature [review] to make definitive conclusions.” Although results suggest probiotics benefit patients with diverticulitis, they are inconclusive, according to Dr. Floch.