Are fibre supplements really necessary in diverticular disease of the colon?

Role of dietary fibre in older adults with asymptomatic (AS) or symptomatic uncomplicated diverticular disease (SUDD): Systematic review and meta-analysis

Dietary fibre and probiotics may play a role in the management of diverticular disease. This systematic review synthesises the evidence on the effects of dietary fibre modifications, with or without the use of probiotics, on the incidence in older adults of asymptomatic (AS) or symptomatic uncomplicated diverticular disease (SUDD), as well as on gastrointestinal function and symptoms. Five electronic databases were searched for studies through to December 2018. The body of evidence was appraised using the Cochrane Risk of Bias tool and GRADE. Nine studies were included, with mean sample ages ranging from 57 to 70 years, and three meta-analyses were performed. Only one study, with high risk of bias, measured the effect of dietary fibre on the incidence of diverticulitis. Dietary fibre supplementation improved stool weight (MD: 42 g/day, P < 0.00001; GRADE level of evidence: low), but had no significant effect on gastrointestinal symptoms (SMD: -0.13, P = 0.16; GRADE level of evidence: low) or stool transit time (MD: -3.70, P = 0.32 GRADE level of evidence: low). There was "very low" confidence for the body of evidence supporting symbiotics for AS or SUDD. A high dietary fibre intake, in line with dietary guidelines, may improve gastrointestinal function and is recommended in patients with AS or SUDD. Dietary fibre supplementation should be considered on an individualised basis to improve bowel function, while any recommendation on symbiotic supplements requires further well-designed research. Future studies should also measure the impact on the incidence of diverticulitis.

Pathophysiology and Therapeutic Strategies for Symptomatic Uncomplicated Diverticular Disease of the Colon

Colonic diverticulosis imposes a significant burden on industrialized societies. The current accepted causes of diverticula formation include low fiber content in the western diet with decreased intestinal content and size of the lumen, leading to the transmission of muscular contraction pressure to the wall of the colon, inducing the formation of diverticula usually at the weakest point of the wall where penetration of the blood vessels occurs. Approximately 20 % of the patients with colonic diverticulosis develop abdominal symptoms (i.e., abdominal pain and discomfort, bloating, constipation, and diarrhea), a condition which is defined as symptomatic uncomplicated diverticular disease (SUDD). The pathogenesis of SUDD symptoms remains uncertain and even less is known about how to adequately manage bowel symptoms. Recently, low-grade inflammation, altered intestinal microbiota, visceral hypersensitivity, and abnormal colonic motility have been identified as factors leading to symptom development, thus changing and improving the therapeutic approach. In this review, a comprehensive search of the literature regarding on SUDD pathogenetic hypotheses and pharmacological strategies was carried out. The pathogenesis of SUDD, although not completely clarified, seems to be related to an interaction between colonic microbiota alterations, and immune, enteric nerve, and muscular system dysfunction (Cuomo et al. in United Eur Gastroenterol J 2:413-442, 2014). Greater understanding of the inflammatory pathways and gut microbiota composition in subjects affected by SUDD has increased therapeutic options, including the use of gut-directed antibiotics, mesalazine, and probiotics (Bianchi et al. in Aliment Pharmacol Ther 33:902-910, 2011; Comparato et al. in Dig Dis Sci 52:2934-2941, 2007; Tursi et al. in Aliment Pharmacol Ther 38:741-751, 2013); however, more research is necessary to validate the safety, effectiveness, and cost-effectiveness of these interventions.

Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking

Background

Diverticulosis is a very common condition. Around 20% of diverticula carriers are believed to suffer from diverticular disease during their lifetime. This makes diverticular disease one of the clinically and economically most significant conditions in gastroenterology. The etiopathogenesis of diverticulosis and diverticular disease is not well understood. Epidemiological studies allowed to define risk factors for the development of diverticulosis and the different disease entities associated with it, in particular diverticulitis, perforation, and diverticular bleeding.

Methods

A comprehensive literature search was performed, and the current knowledge about risk factors for diverticulosis and associated conditions reviewed.

Results

Non-controllable risk factors like age, sex, and genetics, and controllable risk factors like foods, drinks, and physical activity were identified, as well as comorbidities and drugs which increase or decrease the risk of developing diverticula or of suffering from complications. In naming risk factors, it is of utmost importance to differentiate between diverticulosis and the different disease entities.

Conclusion

Risk factors for diverticulosis and diverticular disease may give a clue towards the possible etiopathogenesis of the conditions. More importantly, knowledge of comorbidities and particularly drugs conferring a risk for development of complicated disease is crucial for patient management.

New strategies for the management of diverticular disease: insights for the clinician

Diverticulosis is one of the most common gastrointestinal conditions affecting the general population in the Western world. It is estimated that over 2.5 million people are affected by diverticular disease in the United States. The spectrum of clinical manifestations of diverticulosis ranges from asymptomatic diverticulosis to complicated diverticulitis. Treatment for symptomatic diverticular disease is largely based on symptoms. Traditional therapy includes fiber, bowel rest, antibiotics, pain control and surgery for selected cases. This review discusses recent advances in the medical treatment of diverticular disease such as the use of mesalamine, rifaximin and probiotics as our understanding of the disease evolves.

Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights

Diverticular disease imposes a significant burden on Western and industrialized societies. The traditional pathogenesis model posits that low dietary fiber predisposes to diverticulosis, and fecalith obstruction prompts acute diverticulitis that is managed with broad-spectrum antibiotics or surgery. However, a growing body of knowledge is shifting the paradigm of diverticular disease from an acute surgical illness to a chronic bowel disorder composed of recurrent abdominal symptoms and considerable psychosocial impact. New research implicates a role for low-grade inflammation, sensory-motor nerve damage, and dysbiosis in a clinical picture that mimics irritable bowel syndrome (IBS) and even inflammatory bowel disease (IBD). Far from being an isolated event, acute diverticulitis may be the catalyst for chronic symptoms including abdominal pain, cramping, bloating, diarrhea, constipation, and "post-diverticulitis IBS." In addition, studies reveal lower health-related quality of life in patients with chronic diverticular disease vs. controls. Health-care providers should maintain a high index of suspicion for the multifaceted presentations of diverticular disease, and remain aware that it might contribute to long-term emotional distress beyond traditional diverticulitis attacks. These developments are prompting a shift in therapeutic approaches from widespread antimicrobials and supportive care to the use of probiotics, mesalamine, and gut-directed antibiotics. This review addresses the emerging literature regarding epidemiology, pathophysiology, and management of chronic, symptomatic diverticular disease, and provides current answers to common clinical questions.

Conservative management of complex diverticular disease causing a retroperitoneal perforation

Diverticular disease is very common and may cause symptoms of psoas irritation because of contiguous inflammation arising from the colon affecting the retroperitoneum. Retroperitoneal perforation is rare and is marked by free gas in the adjacent musculature. Rarely infection and associated gas may track into the lower limbs; however, if adequate drainage can be achieved, surgery in the unfit may be avoided. We present a case of a 79-year-old woman with retroperitoneal perforation of diverticular disease presenting with free gas in the leg musculature that was managed conservatively because of associated comorbidities and was associated with the formation of a cutaneous faecal fistula in the lower limb.

Interaction between rifaximin and dietary fibre in patients with diverticular disease

BACKGROUND

Cyclic administration of rifaximin in association with dietary fibre achieves symptomatic relief in uncomplicated diverticular disease (DD) by means of a still undefined mechanism.

AIM

To investigate the effects of a combination of rifaximin and fibre on both hydrogen production by intestinal microflora and oro-anal transit time.

METHODS

In a controlled, double-blind crossover trial, 64 patients with uncomplicated DD were given bran (20 g/day) and randomly treated with rifaximin (1200 mg/day) or a placebo for 14 days. Evaluation was based on clinical status, breath test, oro-anal transit time and faecal weight.

RESULTS

The global symptomatic score was significantly reduced after rifaximin (7.1 +/- 4.1 to 4.1 +/- 3.3; P < 0.005) but not after placebo (6.8 +/- 3.8 to 6.1 +/- 3.5). Hydrogen production significantly increased after placebo from 198 +/- 134 to 267 +/- 161 ppm/min, while Rifaximin reduced it from 222 +/- 187 to 166 +/- 131 ppm/min (P = 0.05). The total oro-anal transit time decreased from 56.1 +/- 28.2 to 51.3 +/- 28.0 h in placebo and from 54.4 +/- 31.9 to 45.1 +/- 32.4 h (P < 0.05) in rifaximin-treated patients.

CONCLUSIONS

The administration of rifamixin improves the benefits of dietary fibre in uncomplicated DD by preventing its bacterial degradation.

Management of diverticular disease: is there room for rifaximin?

Treatment of symptomatic diverticular disease of the colon is aimed at the relief of symptoms and the prevention of major complications. The efficacy of fiber supplementation and of anticholinergic and spasmolytic agents remains controversial. Antibiotics are commonly used in the treatment of inflammatory complications of diverticular disease. Data from open labelled and randomized controlled trials do suggest the efficacy of rifaximin in obtaining symptomatic relief in patients with diverticular disease. Approximately 30% therapeutic gain compared to fiber supplementation only can be expected after one year of intermittent treatment with rifaximin. Considering the safety and tolerability of rifaximin, this drug can be recommended for patients with symptomatic uncomplicated diverticular disease.