Symptomatic Uncomplicated Diverticular Disease (SUDD): Practical Guidance and Challenges for Clinical Management

Giacomo Calini; Mohamed A Abd El Aziz; Lucia Paolini; Solafah Abdalla; Matteo Rottoli; Giulio Mari; David W Larson

doi:10.2147/CEG.S340929

Symptomatic Uncomplicated Diverticular Disease (SUDD): Practical Guidance and Challenges for Clinical Management

Clin Exp Gastroenterol. 2023 Mar 28:16:29-43. doi: 10.2147/CEG.S340929. eCollection 2023.

Authors

Giacomo Calini^{1

2

3

4}, Mohamed A Abd El Aziz^{1

5}, Lucia Paolini⁶, Solafah Abdalla^{1

7}, Matteo Rottoli^{3

4}, Giulio Mari⁸, David W Larson¹

Affiliations

¹ Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
² Department of Medical Area, University of Udine, Udine, Italy.
³ Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
⁴ Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.
⁵ Internal Medicine Department, MercyOne North Iowa, Mason City, IA, USA.
⁶ Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano Bicocca, Monza, Italy.
⁷ Department of Oncologic and Digestive Surgery, Le Kremlin-Bicêtre University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France.
⁸ Department of Laparoscopic and Oncological General Surgery, ASST Brianza, Desio Hospital, Desio, Italy.

Abstract

Symptomatic Uncomplicated Diverticular Disease (SUDD) is a syndrome within the diverticular disease spectrum, characterized by local abdominal pain with bowel movement changes but without systemic inflammation. This narrative review reports current knowledge, delivers practical guidance, and reveals challenges for the clinical management of SUDD. A broad and common consensus on the definition of SUDD is still needed. However, it is mainly considered a chronic condition that impairs quality of life (QoL) and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (eg, diarrhea) and low-grade inflammation (eg, elevated calprotectin) but without systemic inflammation. Age, genetic predisposition, obesity, physical inactivity, low-fiber diet, and smoking are considered risk factors. The pathogenesis of SUDD is not entirely clarified. It seems to result from an interaction between fecal microbiota alterations, neuro-immune enteric interactions, and muscular system dysfunction associated with a low-grade and local inflammatory state. At diagnosis, it is essential to assess baseline clinical and Quality of Life (QoL) scores to evaluate treatment efficacy and, ideally, to enroll patients in cohort studies, clinical trials, or registries. SUDD treatments aim to improve symptoms and QoL, prevent recurrence, and avoid disease progression and complications. An overall healthy lifestyle - physical activity and a high-fiber diet, with a focus on whole grains, fruits, and vegetables - is encouraged. Probiotics could effectively reduce symptoms in patients with SUDD, but their utility is missing adequate evidence. Using Rifaximin plus fiber and Mesalazine offers potential in controlling symptoms in patients with SUDD and might prevent acute diverticulitis. Surgery could be considered in patients with medical treatment failure and persistently impaired QoL. Still, studies with well-defined diagnostic criteria for SUDD that evaluate the safety, QoL, effectiveness, and cost-effectiveness of these interventions using standard scores and comparable outcomes are needed.

Keywords: colonic diverticulosis; diverticulitis; irritable bowel syndrome; microbiota; probiotic; treatment.

Publication types

Review