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BACKGROUND: Diverticular disease of the colon is a common disorder, characterized by recurrent symptoms and complications such as diverticulitis, requiring hospital admissions and surgery. OBJECTIVE: This study aimed to systematically review the evidence for medical therapy of diverticular disease in reducing symptoms and preventing acute diverticulitis. DATA SOURCES: MEDLINE and Embase databases (1966 to February 2010). STUDY SELECTION: The studies selected were prospective clinical trials on uncomplicated diverticular disease of the colon. INTERVENTIONS: Four investigators independently reviewed articles, extracted data, and assessed study quality according to standardized criteria. MAIN OUTCOME MEASURES: The main outcomes measured were improvement in symptoms, complete remission of symptoms, and prevention of acute diverticulitis. RESULTS: We identified 31 studies, including 6 placebo-controlled trials. The methodological quality of these studies was suboptimal. Only 10 trials provided a detailed description of the patient history, 8 assessed symptoms by the use of a validated questionnaire, and 14 appropriately defined inclusion and exclusion criteria. Only one long-term double-blind placebo-controlled study was identified. This reported a significant improvement in symptoms and greater prevalence of symptom-free patients at 1 year with fiber plus rifaximin in comparison with fiber alone. The efficacy of treatment in preventing acute diverticulitis was evaluated in 11 randomized trials. Four trials compared rifaximin plus fiber vs fiber alone and failed to show a significant difference between treatments. However, cumulative data from these trials revealed a significant benefit following rifaximin and fiber (1-year rate of acute diverticulitis: 11/970 (1.1%) vs 20/690 (2.9%); P = .012), but with a number needed to treat of 57, to prevent an attack of acute diverticulitis. LIMITATIONS: : Heterogeneity of the study design, patients' characteristics, regimens and combination of studied treatment, and outcome reporting precluded the pooling of results and limited interpretation. CONCLUSIONS: The treatment for diverticular disease relies mainly on data from uncontrolled studies. Treatment showed some evidence of improvement in symptoms, but its role in the prevention of acute diverticulitis remains to be defined.

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A nutrition rich in fibre has a preventive effect against constipation, colon diverticulosis, carcinoma of the large bowel and stomach, type 2-diabetes, metabolic syndrome and cardiovascular disease. In case of constipation, diverticulosis and diabetes this effect solely depends on dietary fibre. Regarding carcinomas and cardiovascular diseases, so far unknown factors integrated in or associated with fibre-rich food may also contribute to the preventive effect. Therapy with dietary fibre is indicated for constipation, colon diverticulosis, diarrhea, diabetes, and hypercholesterinemia. The individual dietary fibres differ substance-specifically. Food-integrated dietary fibre such as whole-grain bread, vegetables and fruit have their place in prevention. Dietary fibre preparations such as wheat bran, flax seed or sugar-beet fibre are useful in the treatment of constipation, colon diverticulosis and adiposity. Oat bran is preferentially used in hypercholesterinemia. Purified dietary fibres such as cellulose, guar, psyllium, and beta-glucan have an anti-diabetic, all viscous fibres an anti-lipaemic effect. The therapeutic dosages of dietary fibre preparations are 20-40 g/day and of purified fibres substances 10-20 g/day respectively.

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Diverticular disease is common in industrialized countries, and will become more prevalent in the future. Although it is usually a benign condition, treatment with high-fiber diet may prevent complications such as infection, stricture, or bleeding.

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The value of a high-fiber diet in preventing and treating colonic diverticula is firmly established. Although the diagnosis of diverticulosis is usually made with colonoscopy or barium enema examination, computed tomography has become the test of choice during acute diverticulitis, when the diagnosis cannot be confidently made clinically. Recently developed surgical principles for diverticulitis include radiographically directed drainage with delayed operation for peridiverticular abscess, resection of the site of disease in patients with general peritonitis, and primary anastomosis in most cases requiring urgent intervention. Diverticulosis accompanied by abdominal pain or irregular bowel habits is by itself rarely an indication for surgery. Diverticular bleeding usually resolves spontaneously, but persistent bleeding can usually be successfully treated with segmental colectomy after localization of the bleeding site with colonoscopy or arteriography.

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The effect of ispaghula husk on colonic motility of the right and left side was examined in 10 patients with left sided diverticular disease using an untethered pressure sensitive radiotelemetry capsule. After treatment, ispaghula husk reduced mouth to rectum transit by a median of 8.8 hours and the time to midtransverse colon by five hours. In the right colon there was an increase in the median percentage activity of 7% and the median number of pressure waves greater than 5 mm Hg/hour rose by 35.3. Motility changes in the left colon were less pronounced. Five of the seven patients with abdominal pain and six of the nine patients with altered bowel habit responded to treatment. These results suggest that it is ispaghula husk's action on the right unaffected colon which alleviates the symptoms of left sided diverticular disease.

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Twenty original papers that reported on the effect of wheat bran on large bowel function were analysed. Bran increased the stool weight and decreased the transit time in each study in healthy controls and in patients with the irritable bowel syndrome, with diverticula, and with chronic constipation. Statistical evaluation of the data showed, however, that constipated patients had lower stool output and slower transit whether or not they had taken bran, and they responded less well to bran treatment than controls. From these data it is concluded that bran can be expected to be only partially effective in restoring normal stool weight and transit time in patients who are constipated.

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Over the past decade fibre supplementation has achieved widespread acceptance in the management of symptomatic diverticular disease, although the efficacy of this treatment has been debated. We have conducted a retrospective review of 72 patients admitted to hospital with symptomatic diverticular disease over a ten year period in order to determine whether or not high fibre diet afforded protection against the development of complications, necessity for surgery or persistence of symptoms. Fifty-six patients were treated non-operatively, of these 43 received advice concerning a high fibre diet but only 31 patients complied. The 12 patients who failed to take additional fibre and the 13 patients who never received dietary advice (25 patients) formed the non high fibre group. Those treated with fibre supplementation fared significantly better in developing fewer complications and required less surgery (P less than 0.05). At the time of follow-up review patients on a high fibre diet reported significantly fewer symptoms (P less than 0.05).

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Diverticular disease of the colon is a new disease that appeared at the beginning of this century. It is now the commonest disease of the colon in the Western world, being found in 1 in 3 people of over 60 years of age. The pathogenesis of the disease involves excessive segmentation, but this does not explain its aetiology. The historical appearance of the disease on the clinical scene and its geographical distribution suggest that it is due to the removal of fibre from carbohydrates. The author treated 70 patients with symptomatic diverticular disease with a high-fibre diet. The results of this and the effects of bran are discussed.

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