Recurrent diverticulitis: Managing patients and their fears

Like many of you, I see patients with a history of recurrent diverticulitis. These patients come to our clinic frustrated by their unpredictable recurrences and worried the next episode might be catastrophic. Many of these visits are about what the patient fears will happen more than any actual symptoms. They are afraid their pain will come back. They are afraid of surgery and its complications, and they are even afraid that some form of cancer may have been missed. Fortunately, a growing body of literature allows us to offer education and reassurance.

After an initial episode of diverticulitis, a patient’s risk of a first recurrence is 20 to 25 percent. For those who have had a first recurrence, the risk of second recurrence is 40 percent. While we used to believe that multiple recurrences increased the risk of complications, we now understand that complicated disease usually occurs with a patient’s first presentation of diverticulitis. For everyone else, the risk of progressing from uncomplicated to complicated diverticulitis is very low (2 percent within six months). As such, I tell patients with multiple recurrences that while they will likely have another episode, the experience will be similar to past episodes.

Chronic gastrointestinal symptoms after diverticulitis are common and a source of distress. Patients worry something has been missed and come to our clinic looking for a new diagnosis. Misdiagnosed malignancy is only found in ~1 percent of patients initially thought to have diverticulitis. After normal imaging and lower endoscopy, we attribute these symptoms to post-diverticulitis functional bowel disease. We manage these symptoms as we would our patients with functional gastrointestinal disorders. This begins with education. Patients appreciate a mechanistic understanding of their symptoms and are reassured to know this is a common phenomenon.

Most of my clinic patients request diet recommendations. Patients often attribute episodes of diverticulitis to dietary indiscretion. While this guilt may seem confusing, it allows patients some sense of control. If diverticulitis is caused by diet, then a different diet will prevent a recurrence of pain.

Given new data, practice patterns have changed over the past decade, and part of our job is to explain why treatments offered in the past may make less sense now.

We tell our patients that modifiable factors contribute 50 percent of diverticulitis risk. A classic Western diet increases the risk, potentially mediated by gut dysbiosis. This diet includes high intake of red and processed meats, refined grains, sweets, French fries, and high-fat dairy products. Replacing these foods with a diet high in fruits, vegetables, whole grains, legumes, poultry and fish decreases the risk of diverticulitis. While supplemental fiber is easy to recommend, there is no evidence that supplemental fiber is a substitute for the benefits of a prudent diet. Ditto for probiotics.

Obesity and physical inactivity also contribute to diverticulitis risk. The mechanism by which obesity mediates diverticulitis risk is unknown, although preliminary research suggests an inflammatory pathway. Because obesity is also causally linked to cardiovascular disease, diabetes and multiple cancers, helping our patients develop an approach to achieve a healthy body mass index should be a high priority.

Regular use of non-steroidal anti-inflammatory drugs is an important and under-appreciated risk factor for diverticulitis. Non-aspirin non-steroidal anti-inflammatory drugs pose a greater risk than aspirin. Within reason, I recommend avoiding regular use of non-steroidal anti-inflammatory drugs. Whether selective COX-2 inhibitors have a reduced risk is unknown.

Finally, smoking is also a risk factor. As a result, smoking cessation should be discussed with every patient actively using tobacco.

Genetics contribute the remaining 50 percent of diverticulitis risk. Siblings of patients with diverticular disease have three times the risk compared with the general population. Large genome-wide association studies have identified genes with roles in altered colonic neuromuscular function and dysfunctional connective tissues. No genetic overlap with inflammatory bowel disease has been identified.

Because family history may shape patient perception, understanding this history may be a critical part of the visit. A patient who has witnessed a relative undergo a colectomy may wonder if they need one. A patient who has seen a relative on chronic antibiotics to “prevent” recurrences may wonder if a prescription would help them. Given new data, practice patterns have changed over the past decade, and part of our job is to explain why treatments offered in the past may make less sense now.

As recently as 2006, elective colectomy was offered after two episodes of acute uncomplicated diverticulitis. Elective surgery was performed based on the thinking that multiple recurrences increased the risk of perforation and need for urgent colectomy. Again, we now understand that complicated disease usually occurs with a patient’s first presentation of diverticulitis. Excepting patients who are chronically immunosuppressed and at increased risk of complicated disease, elective hemicolectomy is now offered if recurrent episodes are a significant detriment to quality of life. This benefit must outweigh the substantial risks of an elective hemicolectomy.

With a more informed understanding of diverticulitis, we have far more to offer our patients with a history of diverticulitis. While acknowledging there is no easy means for prevention, encouraging patients to adopt a healthy lifestyle has the potential to reduce the risk of recurrent diverticulitis. We can also relay that the natural history of diverticulitis is more benign than previously thought and the threshold for elective surgery has been completely redefined.

Disclosures: Dr. Peery has no conflicts to disclose. Dr. Peery is a member of the AGA Clinical Guideline Committee.

Further reading

Strate L.L., Morris A.M. Epidemiology, pathophysiology, and treatment of diverticulitis. Gastroenterol. 2019;156:1282-1298 e1.

Key takeaways

  • Obesity, smoking, physical inactivity, and a Western diet contribute to ~50 percent of diverticulitis risk.
  • Genes contribute to the other ~50 percent of diverticulitis risk.
  • If diverticulitis is going to be complicated by abscess and/or perforation, it is usually the initial presentation.
  • Elective colectomy is not offered based on the number of episodes, but rather the impact of episodes on a patient’s quality of life.
  • Post-diverticulitis functional bowel disease is common and thought to be mediated by visceral hypersensitivity.

One comment

  • Very nice summary.
    What are your thoughts on use of antibiotics for recurrent episodes of acute diverticulitis?

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