Tag Archives: diverticulitis

Diverticulitis in Adolescents and Adults

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Diverticulitis is rarely seen in the pediatric age group. Over the course of nearly 30 years, I have encountered two cases; though, many of my partners with longer clinical experience have seen none.

If/when you seen diverticulitis, here’s a link to AGA Clinical Practice Update (AF Peery et al. Gastroenterol 2021;160: 906-911): AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review

Recommendations include the following:

  • Best Practice Advice 1: Computed tomography should be considered to confirm the diagnosis of diverticulitis in patients without a prior imaging-confirmed diagnosis and to evaluate for potential complications in patients with severe presentations. Imaging should also be considered in those who fail to improve with therapy, are immunocompromised, or who have multiple recurrences and are contemplating prophylactic surgery in order to confirm the diagnosis and location(s) of disease.
  • Best Practice Advice 3: After an acute episode of diverticulitis, colonoscopy should be delayed by 6–8 weeks or until complete resolution of the acute symptoms, whichever is longer. Colonoscopy should be considered sooner if alarm symptoms are present.
  • Best Practice Advice 5: A clear liquid diet is advised during the acute phase of uncomplicated diverticulitis. Diet should advance as symptoms improve.
  • Best Practice Advice 7: Antibiotic treatment is advised in patients with uncomplicated diverticulitis who have comorbidities or are frail, who present with refractory symptoms or vomiting, or who have a C-reactive protein >140 mg/L or baseline white blood cell count > 15 × 109 cells/L. Antibiotic treatment is advised in patients with complicated diverticulitis or uncomplicated diverticulitis with a fluid collection or longer segment of inflammation on CT scan.
  • Best Practice Advice 9: To reduce the risk of recurrence, patients with a history of diverticulitis should consume a high-quality diet, achieve or maintain a normal body mass index, be routinely physically active, and not smoke. Additionally, patients with a history of diverticulitis should avoid regular use (2 or more times per week) of nonsteroidal anti-inflammatory drugs except aspirin prescribed for secondary prevention of cardiovascular disease.

Holes in the fiber theory

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Since the 1970s, it has been accepted that diverticular disease is related to low fiber intake and the Western diet.  Problem is that this might not be right (Gastroenterology 2012; 142: 205-10).  In this observational cross-sectional study (n=2104), low dietary fiber was not associated with diverticulosis; just the opposite.  High fiber intake, after adjusting for other factors, had an adjusted prevalence ratio of 1.3.  Due to the nature of the study, there may be potential bias that would not be present with a prospective study, especially with regard to dietary recall.  An editorial in the same issue (pg 205-07) lists three other studies; two of these also could not demonstrate a protective effect of fiber.  In addition to these findings, this study did not find an association between fat, red meat, physical activity and diverticulosis.

Although these data throw a big question mark regarding the pathogenesis of diverticular disease, this does not mean you should throw away your fiber bars quite yet.  Although low fiber may not cause diverticular disease, several large prospective studies have been completed which convincing show an association with lower complications/hospitalizations among individuals with higher fiber intake.  In addition, increased fiber in the diet has been shown to lower cardiovascular complications.

Additional references:

  • -Br Med J 1971; 2: 450-54.  Seminal article on diverticular disease and association with Western countries with low fiber intake.
  • -Am J Clin Nutr 1994; 60: 757-64.  Prospective study showing benefits of fiber in preventing diverticular complications (n=47,888); RR=0.58 for developing symptomatic diverticulitis.
  • -BMJ 2011; 343: d4131.  EPIC study, n=47,033, showing benefit of fiber in reducing hospitalizations due to diverticular dz over 12yrs (0.59 RR)
  • -NEJM 1999; 340: 169. fiber does not decrease Colon Ca risk.
  • -NEJM 2000; 342: 1149 & 1159. fiber does not decrease risk of recurrent adenomas.
  • -Am J Clin Nutr 2000; 70: 1433-1438. Fiber lowers cholesterol & can decrease risk of heart attack by 15%.