Diverticular Disease: Reconsidering Conventional Wisdom
2013; Elsevier BV; Volume: 11; Issue: 12 Linguagem: Inglês
10.1016/j.cgh.2013.04.048
ISSN1542-7714
AutoresAnne F. Peery, Robert S. Sandler,
Tópico(s)Urinary and Genital Oncology Studies
ResumoColonic diverticula are common in developed countries and complications of colonic diverticulosis are responsible for a significant burden of disease. Several recent publications have called into question long-held beliefs about diverticular disease. Contrary to conventional wisdom, studies have not shown that a high-fiber diet protects against asymptomatic diverticulosis. The risk of developing diverticulitis among individuals with diverticulosis is lower than the 10% to 25% proportion that commonly is quoted, and may be as low as 1% over 11 years. Nuts and seeds do not increase the risk of diverticulitis or diverticular bleeding. It is unclear whether diverticulosis, absent diverticulitis, or overt colitis is responsible for chronic gastrointestinal symptoms or worse quality of life. The role of antibiotics in acute diverticulitis has been challenged by a large randomized trial that showed no benefit in selected patients. The decision to perform elective surgery should be made on a case-by-case basis and not routinely after a second episode of diverticulitis, when there has been a complication, or in young people. A colonoscopy should be performed to exclude colon cancer after an attack of acute diverticulitis but may not alter outcomes among individuals who have had a colonoscopy before the attack. Given these surprising findings, it is time to reconsider conventional wisdom about diverticular disease. Colonic diverticula are common in developed countries and complications of colonic diverticulosis are responsible for a significant burden of disease. Several recent publications have called into question long-held beliefs about diverticular disease. Contrary to conventional wisdom, studies have not shown that a high-fiber diet protects against asymptomatic diverticulosis. The risk of developing diverticulitis among individuals with diverticulosis is lower than the 10% to 25% proportion that commonly is quoted, and may be as low as 1% over 11 years. Nuts and seeds do not increase the risk of diverticulitis or diverticular bleeding. It is unclear whether diverticulosis, absent diverticulitis, or overt colitis is responsible for chronic gastrointestinal symptoms or worse quality of life. The role of antibiotics in acute diverticulitis has been challenged by a large randomized trial that showed no benefit in selected patients. The decision to perform elective surgery should be made on a case-by-case basis and not routinely after a second episode of diverticulitis, when there has been a complication, or in young people. A colonoscopy should be performed to exclude colon cancer after an attack of acute diverticulitis but may not alter outcomes among individuals who have had a colonoscopy before the attack. Given these surprising findings, it is time to reconsider conventional wisdom about diverticular disease. Podcast interview: www.gastro.org/cghpodcast. Also available on iTunes; see similar articles on pages 1609, 1614, 1622, and 1631 in this issue of Clinical Gastroenterology and Hepatology. Podcast interview: www.gastro.org/cghpodcast. Also available on iTunes; see similar articles on pages 1609, 1614, 1622, and 1631 in this issue of Clinical Gastroenterology and Hepatology. Colonic diverticulosis is extremely common in developed countries. In a consecutive series of 2000 barium enemas at the Massachusetts General Hospital, approximately two thirds of adults older than the age of 85 were found to have colonic diverticula.1Welch C.E. Allen A.W. Donaldson G.A. An appraisal of resection of the colon for diverticulitis of the sigmoid.Ann Surg. 1953; 138: 332-343Crossref PubMed Scopus (92) Google Scholar More recently, diverticulosis was found in 71% of colonoscopies in individuals older than the age of 80.2Everhart J.E. Ruhl C.E. Burden of digestive diseases in the United States part II: lower gastrointestinal diseases.Gastroenterology. 2009; 136: 741-754Abstract Full Text Full Text PDF PubMed Scopus (337) Google Scholar Complications of colonic diverticula are responsible for a significant burden of disease. In 2009, diverticular disease was the sixth most frequent outpatient gastrointestinal diagnosis, with 2.6 million clinic visits.3Peery A.F. Dellon E.S. Lund J. et al.Burden of gastrointestinal disease in the United States: 2012 update.Gastroenterology. 2012; 143: 1179-1187Abstract Full Text Full Text PDF PubMed Scopus (1502) Google Scholar In that same year, diverticular disease was the most common in-patient gastrointestinal diagnosis in the United States with 283,355 hospitalizations at a cost of 2.7 billion dollars.3Peery A.F. Dellon E.S. Lund J. et al.Burden of gastrointestinal disease in the United States: 2012 update.Gastroenterology. 2012; 143: 1179-1187Abstract Full Text Full Text PDF PubMed Scopus (1502) Google Scholar Almost a quarter (22%) of patients admitted with diverticulitis underwent urgent or elective surgery for that condition.4Masoomi H. Buchberg B.S. Magno C. et al.Trends in diverticulitis management in the United States from 2002 to 2007.Arch Surg. 2011; 146: 400-406Crossref PubMed Scopus (118) Google Scholar Diverticula of the large bowel are out-pouchings in the wall of the colon at weak points in the circular muscle where blood vessels penetrate to supply the mucosa.5Slack W.W. The anatomy, pathology, and some clinical features of divericulitis of the colon.Br J Surg. 1962; 50: 185-190Crossref PubMed Scopus (90) Google Scholar Diverticula may be found throughout the colon, but are most common in the sigmoid colon where abnormalities include thickening and elastosis of the teniae, shortening of the bowel, and thickening and folding of the circular muscle.6Hughes L.E. Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis.Gut. 1969; 10: 336-344Crossref PubMed Scopus (294) Google Scholar, 7Hughes L.E. Postmortem survey of diverticular disease of the colon. II. The muscular abnormality of the sigmoid colon.Gut. 1969; 10: 344-351Crossref PubMed Scopus (80) Google Scholar Diverticulosis most often is uncomplicated and asymptomatic. Complications may occur, including bleeding, abscess, perforation, fistula, stricture, or colitis. The term diverticular disease generally is used to denote diverticulosis with a complication. Recent reports have challenged long-accepted dogma. For example, it is widely believed that diverticulosis is the result of a low-fiber diet.8Stollman N.H. Raskin J.B. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology.Am J Gastroenterol. 1999; 94: 3110-3121Crossref PubMed Google Scholar According to conventional wisdom, 10% to 25% of patients with colonic diverticula will develop diverticulitis during their lifetime.8Stollman N.H. Raskin J.B. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology.Am J Gastroenterol. 1999; 94: 3110-3121Crossref PubMed Google Scholar Diverticulosis is thought to be associated with chronic gastrointestinal symptoms in the absence of diverticulitis or overt colitis.9Strate L.L. Modi R. Cohen E. et al.Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.Am J Gastroenterol. 2012; 107: 1486-1493Crossref PubMed Scopus (263) Google Scholar Most physicians believe that diverticulitis is an infection and must be treated with antibiotics.10Jacobs D.O. Clinical practice. Diverticulitis.N Engl J Med. 2007; 357: 2057-2066Crossref PubMed Scopus (390) Google Scholar Elective surgical resection of the affected colon has been recommended after a second attack of diverticulitis and after a first attack in young adults to reduce the risk of recurrence.8Stollman N.H. Raskin J.B. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology.Am J Gastroenterol. 1999; 94: 3110-3121Crossref PubMed Google Scholar Colonoscopy is suggested after an episode of acute diverticulitis to exclude colon cancer.8Stollman N.H. Raskin J.B. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology.Am J Gastroenterol. 1999; 94: 3110-3121Crossref PubMed Google Scholar The goal of this article is to review recent publications that challenge conventional wisdom about diverticular disease. The hypothesis that diverticulosis is a deficiency disease of Western civilization was made popular by Painter and Burkitt based on their observation that diverticulosis was rare in rural Africa, but increasingly common in economically developed countries.11Painter N.S. Diverticular disease of the colon–a disease of the century.Lancet. 1969; 2: 586-588Abstract PubMed Google Scholar, 12Painter N.S. Burkitt D.P. Diverticular disease of the colon: a deficiency disease of Western civilization.Br Med J. 1971; 2: 450-454Crossref PubMed Scopus (626) Google Scholar They attributed the difference in disease prevalence to differences in dietary fiber. They presumed that the rural African diet was high in dietary fiber and that economically developed countries consumed a low-fiber diet. They proposed that this deficiency of fiber predisposed the population to diverticulosis. Neither diet nor diverticulosis was actually measured in their studies and they did not account for important potentially confounding variables such as age and sex. Painter13Painter N.S. Truelove S.C. Ardran G.M. et al.Segmentation and the localization of intraluminal pressures in the human colon, with special reference to the pathogenesis of colonic diverticula.Gastroenterology. 1965; 49: 169-177Abstract Full Text PDF PubMed Google Scholar proposed that the deficiency of fiber led to constipation and high-pressure segmentation of the colon that resulted in mucosal herniation through weak sections of the colon wall. To support their hypothesis they conducted motility studies that compared intracolonic pressures in patients with diverticulosis with intracolonic pressures in controls. Although they reported that patients with diverticulosis had higher colonic pressures, the investigators only reported pressure measurements for select cases and there were no statistical analyses. Motility studies of the colon have not consistently shown that patients with diverticulosis have increased colonic pressures.14Bassotti G. Battaglia E. Spinozzi F. et al.Twenty-four hour recordings of colonic motility in patients with diverticular disease: evidence for abnormal motility and propulsive activity.Dis Colon Rectum. 2001; 44: 1814-1820Crossref PubMed Scopus (110) Google Scholar, 15Parks T.G. Connell A.M. Motility studies in diverticular disease of the colon.Gut. 1969; 10: 534-542Crossref PubMed Scopus (77) Google Scholar, 16Weinreich J. Andersen D. Intraluminal pressure in the sigmoid colon. II. Patients with sigmoid diverticula and related conditions.Scand J Gastroenterol. 1976; 11: 581-586Crossref PubMed Google Scholar, 17Weinreich J. Moller S.H. Andersen D. Colonic haustral pattern in relation to pressure activity and presence of diverticula.Scand J Gastroenterol. 1977; 12: 857-864Crossref PubMed Scopus (15) Google Scholar, 18Leandro P.A. Cecconello I. Habr-Gama A. et al.Gastrointestinal motility in normal subjects and patients with diverticulosis of the colon.Arq Gastroenterol. 1984; 21: 157-163PubMed Google Scholar, 19Viebig R.G. Pontes J.F. Michelsohn N.H. Electromanometry of the rectosigmoid in colonic diverticulosis.Arq Gastroenterol. 1994; 31: 135-144PubMed Google Scholar Along the same lines, Burkitt et al20Burkitt D.P. Walker A.R. Painter N.S. Effect of dietary fibre on stools and the transit-times, and its role in the causation of disease.Lancet. 1972; 2: 1408-1412Abstract PubMed Scopus (823) Google Scholar conducted colonic transit studies and found that a population consuming a Western diet had longer mean colonic transit times and lower mean stool weights compared with an African population. Studies in populations with colonic diverticula, on the other hand, have shown shorter colonic transit times compared with controls.21Manousos O.N. Truelove S.C. Lumsden K. Transit times of food in patients with diverticulosis or irritable colon syndrome and normal subjects.Br Med J. 1967; 3: 760-762Crossref PubMed Scopus (30) Google Scholar, 22Kirwan W.O. Smith A.N. Colonic propulsion in diverticular disease, idiopathic constipation, and the irritable colon syndrome.Scand J Gastroenterol. 1977; 12: 331-335Crossref PubMed Scopus (33) Google Scholar The fiber hypothesis is extremely popular. The concept of forceful contractions of the colon leading to herniation makes sense. However, the hypothesis has persisted for 4 decades largely without proof. Historically it has been a challenge to refute the hypothesis because a proper study would require a structural examination (eg, barium enema) in asymptomatic individuals to document the presence of diverticula. With the widespread use of screening colonoscopy we now have the opportunity to study large numbers of people who are undergoing a structural examination of their colon in the absence of symptoms. We recently published a colonoscopy-based, cross-sectional study of dietary risk factors for diverticulosis.23Peery A.F. Barrett P.R. Park D. et al.A high-fiber diet does not protect against asymptomatic diverticulosis.Gastroenterology. 2012; 142: 266-272Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar Each of the 2104 subjects had a colonoscopy to the cecum between 1998 and 2010. Participants completed a telephone interview that included a comprehensive semiquantitative food frequency questionnaire as well as questions about bowel frequency and physical activity. Contrary to expectation, we found that a high-fiber diet was associated with a higher (not lower) prevalence of diverticula.23Peery A.F. Barrett P.R. Park D. et al.A high-fiber diet does not protect against asymptomatic diverticulosis.Gastroenterology. 2012; 142: 266-272Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar The association with dietary fiber intake was dose-dependent and stronger when limited to cases with multiple diverticula. We also found that constipation was not a risk factor for diverticulosis. Instead, we found that participants who had regular bowel movements (7 bowel movements/wk) had a 34% higher risk of diverticulosis compared with participants who had less frequent bowel movements (<7 bowel movements/wk). Study participants were interviewed after their colonoscopy and were aware, in most cases, that diverticulosis had been found. In response to the concern that the study may have been susceptible to response bias and reverse causality from the subjects' knowledge of their diagnoses,24Strate L.L. Diverticulosis and dietary fiber: rethinking the relationship.Gastroenterology. 2012; 142: 205-207Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar we performed a second cross-sectional study in a different population in which we limited the analysis to participants with no knowledge of their diverticulosis status. The second study confirmed the results of the initial work (unpublished data). Similar results with respect to fiber were found in 2 colonoscopy-based studies in non-Western populations, although diverticula in Asia are found predominantly in the right colon and may have a different etiology.25Song J.H. Kim Y.S. Lee J.H. et al.Clinical characteristics of colonic diverticulosis in Korea: a prospective study.Korean J Intern Med. 2010; 25: 140-146Crossref PubMed Scopus (92) Google Scholar, 26Lin O.S. Soon M.S. Wu S.S. et al.Dietary habits and right-sided colonic diverticulosis.Dis Colon Rectum. 2000; 43: 1412-1418Crossref PubMed Scopus (50) Google Scholar Although recent studies have suggested that a high-fiber diet does not protect against the development of diverticulosis23Peery A.F. Barrett P.R. Park D. et al.A high-fiber diet does not protect against asymptomatic diverticulosis.Gastroenterology. 2012; 142: 266-272Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar there is some evidence that a high-fiber diet may protect against diverticular disease. Crowe et al27Crowe F.L. Appleby P.N. Allen N.E. et al.Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians.BMJ. 2011; 343: d4131Crossref PubMed Scopus (237) Google Scholar studied 47,033 men and women in England and Scotland. Individuals who reported consuming a vegetarian diet had a lower risk of admission to the hospital or death from diverticular disease. There was also an inverse association for fiber intake. Those in the highest quintile of fiber consumption were 41% less likely to have a complication from diverticular disease. Similar results were seen in a prospective study of US male health professionals.28Aldoori W.H. Giovannucci E.L. Rockett H.R. et al.A prospective study of dietary fiber types and symptomatic diverticular disease in men.J Nutr. 1998; 128: 714-719Crossref PubMed Scopus (260) Google Scholar It is important to recognize that the research to date was designed to improve our understanding of risk factors for diverticulosis and its complications and not to make dietary recommendations. There are advantages to eating a high-fiber, plant-based diet with respect to constipation, heart disease, and cancer.29Anderson J.W. Baird P. Davis Jr., R.H. et al.Health benefits of dietary fiber.Nutr Rev. 2009; 67: 188-205Crossref PubMed Scopus (1470) Google Scholar, 30Aune D. Chan D.S. Lau R. et al.Dietary fibre, whole grains, and risk of colorectal cancer: systematic review and dose-response meta-analysis of prospective studies.BMJ. 2011; 343: d6617Crossref PubMed Scopus (753) Google Scholar It is generally reported that 10% to 25% of patients with diverticulosis will develop diverticulitis during their lifetime.31Stollman N. Raskin J.B. Diverticular disease of the colon.Lancet. 2004; 363: 631-639Abstract Full Text Full Text PDF PubMed Scopus (515) Google Scholar This estimate is based on a widely cited review of the natural history of diverticular disease published by Parks32Parks T.G. Natural history of diverticular disease of the colon.Clin Gastroenterol. 1975; 4: 53-69Crossref PubMed Google Scholar in 1975. The largest case series, published almost 3 decades earlier in 1947, included 47,000 roentgenologic examinations of the colon.33Pemberton J.D. Black B.M. Maino C.R. Progress in the surgical management of diverticulitis of the sigmoid colon.Surg Gynecol Obstet. 1947; 85: 523-534PubMed Google Scholar Diverticulosis was diagnosed in 8.5% of the examinations. Of the patients with diverticulosis, 15% were diagnosed with diverticulitis. Because the study did not include any formal description of the methods, the indication for the original roentgenologic examination and the criteria for a diagnosis of diverticulitis are unknown. A 1958 case series described the natural history of diverticulosis in 300 patients diagnosed with diverticulosis by double-contrast barium enema.34Horner J.L. Natural history of diverticulosis of the colon.Am J Dig Dis. 1958; 3: 343-350Crossref PubMed Scopus (109) Google Scholar A diagnosis of diverticulitis was made for patients who subsequently presented with acute constipation or diarrhea, abdominal cramping, localized tenderness, fever, and leukocytosis. In that study, 10% of patients with diverticulosis developed diverticulitis over a follow-up period of 1 to 5 years. Among those followed up for 6 to 10 years, 25% developed diverticulitis. Smaller case series also have reported estimates of the risk of developing diverticular disease in those with diverticulosis.35Boles Jr., R.S. Jordan S.M. The clinical significance of diverticulosis.Gastroenterology. 1958; 35: 579-582Abstract Full Text PDF PubMed Google Scholar To accurately calculate the cumulative incidence of diverticulitis it would be necessary to enroll a population of patients with diverticulosis and no history of diverticulitis. These individuals then would be observed over time for the development of diverticulitis. The widely quoted estimates are based on studies that were performed more than 50 years ago and potentially were biased. The studies began with patients who sought medical care and subsequently received a diagnosis of diverticulosis. This approach selects a population more likely to have diverticular disease and thus likely overestimates the risk of diverticulitis. Furthermore, these studies only included patients who were followed up in subsequent visits. Patients with diverticulosis without any symptoms were less likely to attend a follow-up visit. Recent data suggest that the lifetime risk of diverticulitis is lower than commonly cited. Shahedi et al36Shahedi K.F.G. Bolus R. et al.Progression from incidental diverticulosis to acute diverticulitis.Gastroenterology. 2012; 142: S144Abstract Full Text PDF Google Scholar estimated the incidence of acute diverticulitis in a retrospective cohort of veterans with diverticulosis incidentally found on colonoscopy. The risk of diverticulitis confirmed by computerized tomography (CT) scan or surgery was 1% over 11 years of follow-up evaluation. With the widespread use of colonoscopy for screening for colorectal cancer, many patients are being given a diagnosis of diverticulosis and then warned that their risk of a complication is 1 in 4. This prediction appears to be exaggerated. For more than 50 years, patients with diverticulosis were advised to avoid foods that may leave coarse particulate in the stool (ie, nuts, corn, and seeds).10Jacobs D.O. Clinical practice. Diverticulitis.N Engl J Med. 2007; 357: 2057-2066Crossref PubMed Scopus (390) Google Scholar, 34Horner J.L. Natural history of diverticulosis of the colon.Am J Dig Dis. 1958; 3: 343-350Crossref PubMed Scopus (109) Google Scholar, 37Salzman H. Lillie D. Diverticular disease: diagnosis and treatment.Am Fam Physician. 2005; 72: 1229-1234PubMed Google Scholar This recommendation was based on the hypothesis that these particles might obstruct a narrow-necked diverticulum or physically abrade a diverticulum, thereby initiating a cascade of events resulting in diverticulitis or diverticular hemorrhage. In a landmark study, Strate et al38Strate L.L. Liu Y.L. Syngal S. et al.Nut, corn, and popcorn consumption and the incidence of diverticular disease.JAMA. 2008; 300: 907-914Crossref PubMed Scopus (222) Google Scholar found that dietary nuts, corn, and seeds were not associated with an increased risk of diverticulitis or diverticular bleeding in a prospective cohort of male health professionals. A recent taxonomy of diverticular disease terms distinguishes several types of symptomatic disease.9Strate L.L. Modi R. Cohen E. et al.Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.Am J Gastroenterol. 2012; 107: 1486-1493Crossref PubMed Scopus (263) Google Scholar The taxonomy includes 2 types of chronic diverticulitis: chronic recurrent diverticulitis and segmental colitis associated with diverticulosis.9Strate L.L. Modi R. Cohen E. et al.Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.Am J Gastroenterol. 2012; 107: 1486-1493Crossref PubMed Scopus (263) Google Scholar Chronic recurrent diverticulitis may begin early after the initial episode, and may be consistent with failure of the index episode to “settle.”39Eglinton T. Nguyen T. Raniga S. et al.Patterns of recurrence in patients with acute diverticulitis.Br J Surg. 2010; 97: 952-957Crossref PubMed Scopus (124) Google Scholar Segmental colitis associated with diverticulosis is defined as peridiverticular colitis that spares the rectum.9Strate L.L. Modi R. Cohen E. et al.Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.Am J Gastroenterol. 2012; 107: 1486-1493Crossref PubMed Scopus (263) Google Scholar It is not surprising that patients with chronic recurrent diverticulitis and segmental colitis associated with diverticulosis have symptoms, given their measurable colonic inflammation. Another category of chronic disease has been termed symptomatic uncomplicated diverticular disease and is defined as diverticulosis associated with chronic gastrointestinal symptoms in the absence of diverticulitis or overt colitis.9Strate L.L. Modi R. Cohen E. et al.Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.Am J Gastroenterol. 2012; 107: 1486-1493Crossref PubMed Scopus (263) Google Scholar The criteria for a diagnosis of symptomatic uncomplicated diverticular disease do not include a history of acute diverticulitis. The literature on symptomatic uncomplicated diverticular disease is limited and confusing. For example, a small Italian study administered a general quality-of-life survey (Short-Form 36) to 58 outpatients who met the criteria for symptomatic uncomplicated diverticular disease and had symptoms of abdominal pain/discomfort, bloating, tenesmus, diarrhea, abdominal tenderness, fever, or dysuria.40Comparato G. Fanigliulo L. Aragona G. et al.Quality of life in uncomplicated symptomatic diverticular disease: is it another good reason for treatment?.Dig Dis. 2007; 25: 252-259Crossref PubMed Scopus (76) Google Scholar Not surprisingly, the quality-of-life scores were lower than a normative Italian population at baseline. It is not possible to conclude that either the symptoms or the decrement in quality of life were the result of diverticulosis. At 6 months, quality-of-life scores had improved, suggesting that the initial low scores were caused by diverticulitis or other acute illness at baseline. In another study, 12 patients with symptomatic uncomplicated diverticular disease were compared with 13 controls. The diverticular disease patients were found to have visceral hypersensitivity based on rectal barostat studies, perhaps mediated by ongoing inflammation and up-regulation of tachykinins based on colonic histology.41Humes D.J. Simpson J. Smith J. et al.Visceral hypersensitivity in symptomatic diverticular disease and the role of neuropeptides and low grade inflammation.Neurogastroenterol Motil. 2012; 24 (318–e163)Crossref PubMed Scopus (101) Google Scholar In contrast, a study of 784 subjects who had a structural examination of their colon found that the frequency of abdominal pain, diarrhea, constipation, and irritable bowel was similar in patients with and without diverticulosis.42Kang J.Y. Firwana B. Green A.E. et al.Uncomplicated diverticular disease is not a common cause of colonic symptoms.Aliment Pharmacol Ther. 2011; 33: 487-494Crossref PubMed Scopus (16) Google Scholar The study used Rome criteria for irritable bowel syndrome (IBS) to classify patients and the response rates were high. Subjects completed questionnaires before structural examinations. This study casts doubt on whether diverticulosis is associated with chronic symptoms. Symptomatic uncomplicated diverticular disease simply may be irritable bowel syndrome in patients who are found to have diverticulosis because they undergo colonoscopy. A population-based, cross-sectional study found an increased risk for colonic diverticulosis among patients with irritable bowel syndrome compared with those without.43Jung H.K. Choung R.S. Locke 3rd, G.R. et al.Diarrhea-predominant irritable bowel syndrome is associated with diverticular disease: a population-based study.Am J Gastroenterol. 2010; 105: 652-661Crossref PubMed Scopus (116) Google Scholar Whether IBS and diverticular disease share an underlying pathophysiology or whether patients with IBS symptoms are simply more likely to undergo structural examinations that reveal diverticulosis is uncertain. Some patients appear to have chronic abdominal pain after a bout of diverticulitis. This postdiverticulitis IBS may be akin to the IBS that develops after an acute bowel infection (postinfectious IBS), and would seem more appropriately considered a form of IBS rather than a type of chronic diverticular disease. In summary, it is unclear whether diverticulosis, in the absence of diverticulitis or overt inflammation, is responsible for chronic gastrointestinal symptoms or decreased quality of life. The prevalence of diverticulosis approaches 80% in 80 year olds. The vast majority of those individuals do not have symptoms. We need more research to identify the subset that has symptoms and to determine why. A 2007 New England Journal of Medicine review on diverticulitis recommended that mild attacks of acute diverticulitis should be treated with 7 to 10 days of oral broad-spectrum antibiotics.10Jacobs D.O. Clinical practice. Diverticulitis.N Engl J Med. 2007; 357: 2057-2066Crossref PubMed Scopus (390) Google Scholar The review noted that the pathogenesis of diverticulitis is unknown but restated the common hypothesis that diverticulitis is the result of an obstruction at the neck of the diverticulum, mucosal abrasion, low-grade inflammation, and bacterial translocation. Mild diverticulitis is thought to be associated with microperforation and more severe disease, gross perforation. In short, all manifestations of diverticulitis have been presumed to be caused by infection that should be treated with antibiotics. A recent multicenter randomized controlled trial in Sweden and Iceland recruited 623 patients who had typical symptoms, uncomplicated left-sided diverticulitis documented by CT scan, and a temperature higher than 38°C.44Chabok A. Pahlman L. Hjern F. et al.Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis.Br J Surg. 2012; 99: 532-539Crossref PubMed Scopus (410) Google Scholar
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