Diverticular Disease: Drug Therapy

Therapy goals

  • Improvement of the symptomatology
  • Avoidance of complications

Therapy recommendations

Food restriction for pain relief. NSAIDs should be avoided because of evidence of increased perforation rate and increased recurrence rate (recurrence of disease). Avoidance of antibiotic therapy can be justified under the following conditions:

  • Patients without a fever ≥ 39 °C; and
  • Without risk factors (e.g., immunosuppression),
  • In whom complicated diverticulitis could be excluded by CT.

In acute complicated diverticulitis, parenteral antibiotic therapy should be given under inpatient conditions. Acute diverticulitis:

  • In acute uncomplicated left-sided diverticulitis (type 1a/type 1b), antibiotic therapy should be administered in patients with risk indicators for a complicated course (arterial hypertension/high blood pressure, chronic kidney disease, immunosuppression (suppression of the immune system), allergic disposition) [consensus strength: consensus, recommendation strength: recommendation].
  • In acute uncomplicated left-sided diverticulitis without risk indicators for a complicated course, antibiotic therapy can be omitted under close clinical control [consensus strength: consensus, recommendation strength: open recommendation]This approach is confirmed by a randomized observational study. According to a meta-analysis, antibiotic therapy also does not provide statistically significant benefits in patients at increased risk for an unfavorable course (VAS pain score > 7, leukocytes > 13.5 x 109/l).Risk indicators for a complicated course are arterial hypertension, chronic kidney disease, immunosuppression, allergic disposition.
  • Right-sided diverticulitis should be treated according to the same therapeutic principles as left-sided diverticulitis [consensus strength: strong consensus, recommendation strength: recommendation).
  • Patients with complicated diverticulitis (type 2a: microabscess) should be hospitalized. [consensus strength: strong consensus, recommendation strength: strong recommendation]
    • Parenteral (“bypassing the intestine”) fluid substitution should be performed when oral hydration is inadequate
    • Oral and nutritional supplementation may be performed depending on the clinical situation
    • In complicated diverticulitis, antibiotic therapy should be performed (blood cultures for pathogen diagnosis beforehand)

Chronic diverticulitis:

Symptomatic uncomplicated diverticular disease (SUDD) is distinguished from uncomplicated recurrent diverticular disease/diverticulitis:

  • Type 3a – diverticular disease with persistent symptoms, signs of inflammation optional.
  • Type 3b – Recurrent diverticulitis without complications.
  • Symptomatic uncomplicated diverticular disease can be treated with mesalazine (oral; anti-inflammatory drug) [consensus strength: consensus, recommendation strength: open recommendation]Two randomized double-blind placebo-controlled trials (PREVENT1 and PREVENT2) in patients with at least one previous episode of confirmed acute uncomplicated diverticulitis found no significant effect of mesalazine on the end points studied (recurrences or quality of life). Further studies support these.
  • A general recommendation for conservative secondary prophylaxis of recurrent diverticular disease (diet, lifestyle, physical activity, medications [mesalazine, probiotics, rifaximin]) cannot be given because of insufficient data. [Consensus Strength: Strong Consensus, Recommendation Strength: Open Recommendation]

Further references

  • Diverticular bleeding and anticoagulation (anticoagulation): according to one study, treatment with antiplatelet drugs (drugs that inhibit platelet clumping) after an initial bleed was significantly associated with an increased risk of subsequent bleeding, almost 1.5-fold (hazard ratio [HR]: 1.47; 95% confidence interval: 1.15-1.88).Patients who had received anticoagulation for apoplexy prophylaxis (stroke prophylaxis) at the time of a first detected diverticular hemorrhage were not more likely to have a second hemorrhage, regardless of which drug they were taking (HR: 0.98; 95% confidence interval: 0.89-1.22). If anticoagulation had been discontinued after the first bleeding, the risk of apoplexy was increased by almost 2-fold (HR: 1.93; 95% confidence interval: 1.17-3.19).

Conservative therapy versus surgical therapy:

  • If adequate conservative therapy does not result in cure of acute uncomplicated diverticulitis, surgical therapy should be considered after exclusion of a complication or other diseases. [Consensus strength: strong consensus, recommendation strength: recommendation]
  • Successfully treated acute uncomplicated diverticulitis (type Ia and type Ib) is not an indication for surgery. [consensus strength: strong consensus, recommendation strength: negative recommendation]
  • After successfully treated acute uncompli cated diverticulitis (type Ia and Ib) in patients with risk indicators for recurrence (recurrence of disease) and complications (eg, transplantation, immunosuppression, chronic systemic glucocorticoids), surgery may be indicated. [Consensus strength: strong consensus, recommendation strength: open recommendation.]
  • Failure to respond to adequate conservative therapy for complicated diverticulitis (type II a – b) should result in surgery with deferred urgency. [consensus strength: strong consensus, recommendation strength: recommendation]
  • In patients with successfully treated complicated diverticulitis (macroperforation/severe intestinal rupture, abscess/encapsulated pus cavity) (type IIb), surgery should be recommended during the inflammation-free interval. [consensus strength: consensus, recommendation strength: recommendation]
  • Patients with free perforation and peritonitis in acute complicated diverticulitis should be operated immediately after diagnosis (emergency surgery). [Consensus strength: strong consensus, recommendation strength: strong recommendation.]
  • Postdiverticulitis stenosis (narrowing) is clinically relevant if it results in obstruction of fecal passage requiring treatment. A clinically relevant stenosis should be operated on urgently, early electively, or electively, depending on the clinical findings. [consensus strength: strong consensus , recommendation strength: recommendation]
  • Chronic recurrent uncomplicated diverticulitis (type IIIb) should be operated only after careful risk-benefit assessment depending on the individual symptoms, if possible in the inflammation-free interval (individual medical decision). A general elective interval surgery depending on the number of previous inflammatory relapses is not justified. [Consensus strength: strong consensus, recommendation strength: recommendation / negative recommendation]

Supplements (dietary supplements; vital substances)

Suitable supplements due todiverticulitis should contain the following vital substances:

  • Vitamins (cobalamin* (vitamin B12))
  • Trace elements (iron* )
  • Probiotics* *

Legend:* Risk group* * Therapy.

Suitable supplements for natural defense should contain the following vital substances:

A typical representative of probiotics are lactobacilli. These are lactic acid bacteria that can break down sugar to lactic acid. They occur naturally in the human intestine. Note: The listed vital substances are not a substitute for drug therapy. Food supplements are intended to supplement the general diet in the particular life situation.