Update on Diverticular Disease Management

Diverticular disease affects 2.5 million people in the United States. Symptoms of diverticular disease include abdominal pain, bloating, and change in bowel habits.

Multiple factors are thought to contribute to the occurrence of the disease, including straining to defecate which raises the intraluminal pressure. The disease tends to recur most in male patients 40-50 years of age.

Diverticular disease includes conditions such as diverticulosis and diverticulitis. Diverticulosis is characterized by chronic inflammation. It is thought to occur because of alterations in pro and anti-inflammatory cytokines in the gut. In symptomatic diverticulosis, hypertrophy and higher motility occurs in the affected areas.

An increase of interleukin-1 (IL-1) and tumor necrosis factor-alpha, and a decrease in anti-inflammatory cytokines IL-1 receptor antagonist, IL-4, IL-10, and IL-11 are associated with the development of diverticulitis.

Diverticulitis is an acute inflammation or infection of the diverticula. Data shows that most people with diverticulosis will not develop diverticulitis.

Recent researchindicates that the management of diverticular disease in the primary care setting should consist of a more active approach.

Risk factors for the development of the disease include: diets low in fiber; >7 bowel movements/week; high intake of red or processed meat; lack of vitamin D; alcohol use; obesity; positive first-degree family history; smoking; and sedimentary lifestyle. Management of the disease focuses on eliminating symptoms, preventing infection, and controlling chronic inflammation.

Treatment recommendations include diet modification and the use of antibiotics during acute diverticulitis. Patients with uncomplicated diverticulitis should be on a clear liquid diet. Patients with nausea, vomiting, and dehydration should be admitted to the hospital for intravenous therapy and pain management (with the use of morphine sulfate being contraindicated due to colon spasm).

Differentiation of uncomplicated and complicated diverticulitis can be made by evaluating CBC, C-reactive protein, and sedimentation rate. The most commonly isolated bacteria found in acute diverticulitis are E-coli, Bacteroides fragilis, and Clostridia species.

The most common antibiotic combination used in diverticulitis is ciprofloxacin and metronidazole to cover both gram-negative and anaerobic bacteria, as well as Augmentin, in the outpatient setting. Probiotics show a decrease in symptoms due to restoration of normal gut flora.

The use of antispasmodics may relieve pain and bloating. Mesalamine or rifamixin can be considered in treatment-resistant disease or incomplete resection.

The authors state that it is imperative for nurse practitioners to recognize the symptoms of diverticular disease and to investigate them further as they can mimic other diseases. If diverticular disease is diagnosed, the patient must be educated on proper diet and lifestyle modifications.

Probiotics and vitamin D supplements can be recommended to appropriate patients as well as avoidance of NSAIDS, which can cause GI bleeding. The prescribing of non-OTC medications should be tailored to each patient.

Patients who present with diverticulitis should be referred to a specialty provider for chronic treatment.