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Rapid response to:

Clinical Review

Management of diverticulitis

BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7536.271 (Published 02 February 2006) Cite this as: BMJ 2006;332:271

Rapid Response:

Clinical management of colonic diverticulitis

Sir,

I read with interest the recent review by Simon Janes and colleagues about
the management of diverticulitis (1). I mean that this review may be
considered as surgical review rather than a medical/surgical review, and
that it deserves some consideration.

This first point is related to the definition of diverticulitis. Looking
at the box 1 of the review, and according to the current clinical
classification of the disease (2), term diverticulitis was used to
indicated superadded inflammation involving the bowel wall, ranging from
microperforation to all complication related to diverticular disease:
hemorrhage, abscess, phlegmon, perforation, purulent and fecal
peritonitis, stricture, fistula, small-bowel obstruction due to post-
inflammatory adhesions.

Considering this, all patients affected by colonic inflammation in
diverticular disease should be considered affected by complicated
diverticular disease, and treated therefore with bowel rest and
intravenous antibiotic therapy (2). However, it is common practice that
several cases of the so-called “uncomplicated diverticulitis” or
“sigmoiditis” may be successfully treated with oral antibiotic therapy and
reduction of amount of fiber (about 5-15 gr/day) (3). Moreover, the large
diffusion of colonoscopy as first-line approach to exclude colorectal
cancer has given surprising results. In fact it is a common finding in
clinical practice that colonoscopy may show endoscopic picture of acute
diverticular inflammation in patients complaining for mild, non-specific
symptoms (abdominal pain without any signs or symptoms of complicated
disease). This common experience is reinforced by the results of a recent
prospective study: in a series of 2566 consecutive patients undergoing
colonoscopy, 0.8% showed evidence of acute diverticular inflammation
(erytema and edema of the opening, pus, polypoid mass, or granulation
tissue in the diverticulum), but surprisingly none of them complained for
clinical symptoms (4). How should we classify these patients? Moreover,
it is quite common in clinical practice to recognize patients affected by
diverticular disease with increased inflammatory indices (erytrocyte-
sedimentation-rate, C-reactive protein, etc) and with endoscopic picture
of inflamed diverticula but without complications (absence of stenosis,
abscesses, perforations, fistulas, etc.). These patients experience a
quick clinical recovery after a short course of oral antibiotic therapy,
and more recently also after mesalazine treatment (5,6). May be they
considered as suffering from “uncomplicated diverticulitis”?

Recent observations suggest a further understanding of the natural history
of diverticular disease as a chronic inflammatory bowel disease. Since it
is now accepted that low-fiber diets are associated with diverticular
formation, it must be noted that low-fiber diets results in an altered
microecology. Experimentally in humans was demonstrated that wheat bran
alters anaerobic/aerobic bacterial ratios (7). Isolauri and many others
have shown that altering the flora will change the immune response of the
host and the colon (8). Moreover, some recent studies did reveal chronic
inflammation associated to diverticula formation (9,10), and this chronic
inflammation seems to be related to the severity of the disease (11).

Therefore, there is evidence that fiber deficiency is associated with an
altered bacterial microecology. Altered microecology may be associated
with a decreased colon mucosal immune response, and there is evidence
that chronic inflammation occurs in the mucosa associated with
diverticula. A long-term history of chronic inflammation may lead to
diverticulitis, first uncomplicated (confined to the bowel wall) and then
complicated (with extension outside the bowel wall).

The second point is related to the treatment of post-diverticulitis
stenoses. Recurrent attacks of diverticulitis may lead to progressive
fibrosis and stricturing of the colonic wall in the absence of ongoing
inflammation. In such cases, high grade or complete obstruction can occur
rendering ineffective medical therapy and requiring surgery.

A first study conducted on 1997 found probiotic administration after a
course of rifaximin, if done cyclically, effective in controlling symptoms
and in obtaining resolution in at least 50% of pastients with post-
diverticulitis stenoses (12). On 2002 we performed a study on patients
affected by diverticulitis, suffering from at least two attacks of acute
diverticulitis in the previous year. We found that that if the cyclic
treatment with rifaximin and mesalazine starts quickly after diagnosis, it
can obtain resolution of slight/moderate colonic obstruction in most of
patients without surgery (13).

It is hypothesize therefore that in these patients the development of
fibrosis is slower than previously hypothesized or, more probably, that a
rapid starting therapy may stop the development of fibrosis.

The last point is related to the prevention of diverticulitis recurrence.
The authors did not discussed this important point in their review. Each
repeated episode of diverticulitis responds less to medical therapy. The
combination of soluble dietary fiber and rifaximin seems to be effective
in this respect. In fact the treatment with rifaximin not only halves the
relative risk of hospital readmission for complications, but also reduces
by 73% the risk of re-operation (14). Like for symptomatic relief, the
addition of mesalazine to rifaximin almost completely prevented the
recurrence of diverticulitis, whise rate in patients treated with both
drugs fell to only 2.7%(13).

In light of these consideration it is hypothesized that the use of
antiinflammatory drugs, with or without antibiotic, and probiotics could
faster induce the remission and seem to be effective in reducing
complications: this conservative approach may considerably reduce the
number of patients requiring surgery or other non medical therapies.
Further, blinded studies are warranted in this respect.

REFERENCES

1) Janes SJ, Meagher A, Frizelle FA. Management of diverticulitis. BMJ
2006;332: 271-5

2) Results of a Consensus Development Conference. Diagnosis and treatment
of diverticular disease. Surg Endosc 1999;13: 430-6

3) Floch MH, Bina I. The natural history of diverticulitis – Fact and
Theory. J Clin Gastroenterol 2004;38: S2-7

4) Ghorai S, Ulbright TM, Rex DK. Endoscopic findings of diverticular
inflammation in colonoscopy patients without clinical acute
diverticulitis: prevalence and endoscopic spectrum. Am J Gastroenterol
2003;98: 802-6

5) Tursi A. Acute diverticulitis of the colon – current medical
therapeutic management. Expert Opin Pharmacother 2004;5: 145-9

6) Tursi A. Mesalazine for diverticular disease of the colon – a new role
for an old drug. Expert Opin Pharmacother 2005;6: 69-74

7) Floch MH, Fuchs H-M. Modification of stool content by increased bran
intake. J Clin Nutr 1978 ;31(suppl): 185-9

8) Isolauri E, Sütas Y, Kankaapää P, Arvilommi H, Salminen S. Probiotics:
effect on immunity. Am J Clin Nutr 2001;73(suppl): 444-50

9) Narayan R, Floch MH. Microscopic colitis as part of the natural history
of diverticular disease (Abstract). Am J Gastroenterol 2002;97(suppl):
112.

10) Morini S, Hassan C, Zullo A et al. Epithelial cell proliferation of
the colonic mucosa in diverticular disease: a case-control study. Aliment
Pharmacol Ther 2005;21: 1385-90

11) Tursi A, Brandimarte G, Elisei W, Inchingolo CD, Aiello F. Epithelial
cell proliferation of the colonic mucosa in different degrees of colonic
diverticular disease. J Clin Gastroenterol 2006;40: 306-11

12) Giaccari S, Tronci S, Falconieri M, Ferrieri A. Long-term treatment
with rifaximin and lactobacilli in post-diverticulitic stenoses of the
colon. Eur Rev Med Pharmacol Sci 1993; 15: 29-34

13) Tursi A, Brandimarte G, Daffinà R. Long-term treatment with mesalazine
and rifaximin versus rifaximin alone for the patients with recurrent
attacks of acute diverticulitis of the colon. Digest Liver Dis 2002;34:
510-515

14) Porta A, Germano A, Frieri A, Koch M. The natural history of
diverticular disease of the colon: a role for antibiotics in preventing
complications? Eur Rev Med Pharmacol Sci 1994;16: 33-39

Competing interests:
None declared

Competing interests: No competing interests

30 June 2006
Antonio Tursi
Consultant gastroenterologist
Digestive Endoscopy Unit, “Lorenzo Bonomo” Hospital, 70031 Andria (BA) - Italy