Digestive disorders

II/4.6: Therapy

In patients with symptoms and no complications, antispasmodic therapy may be administered in addition to nutritional therapy (insoluble dietary fibers). Rifaximin, an unabsorbable semisynthetic rifamycin analog, when used continuously (for 1 year) or in cycles (for 1 week in every month) with dietary fiber supplementation may alleviate the complaints in patients with uncomplicated diverticulosis, as well as it may reduce the risk of complications; however further studies are required in order to confirm the results.

Of the anti-inflammatory drugs 5-aminosalicylates (mesalazine) are agents used in patients with mild to moderate inflammatory bowel disease. In patients with uncomplicated diverticulitis associated with symptoms they may alleviate complaints and reduce the rate of complications. A combination of aminosalicylates with rifaximin may be more effective.

Probiotics are living microorganisms which may be beneficial when given into the digestive tract in a sufficient amount. Combined with 5-aminosalicylates or unabsorbable antibiotics they are beneficial due to changing the intestinal flora and reducing the inflammation; confirmation is yet required relating to their use.

In patients with diverticulitis a liquid diet free from fibers and an antibiotic therapy effective also against Gram-negative rods and anaerobic bacteria (ciprofloxacin, metronidazole) orally or, in more severe cases, parenterally should be administered for 7 to 10 days. In severe cases patients require hospitalization; in addition to fasting and parenteral fluid replacement, intravenous broad-spectrum antibiotic treatment (e.g. piperacillin/tazobactam, ampicillin/sulbactam or second or third generation cephalosporins completed with metronidazole or possibly clindamycin, effective also against anaerobic bacteria) is indicated for 10 to 14 days.

15 to 30% of patients require surgery due to ineffectiveness of conservative therapy. A change of approach occurred relating to surgical treatment of the disease, indication of surgery and timing of the intervention. Earlier a surgery was taken into consideration solely in patients with complicated diverticulitis, when diffuse peritonitis, fistula developed or an obstruction or significant hemorrhage occurred. Emergency surgery (Hartmann’s operation) includes resection of the intestinal segment affected by inflammation, and formation of an end colostomy with a rectal stump remaining. The closure of Hartmann’s procedure has high postoperative morbidity and mortality, and it is also technically not simple; therefore elective surgery has come into the forefront. Elective resection of the colonic segment affected by diverticulitis was recommended previously after the second episode of uncomplicated diverticulitis. Individual consideration is advised by the most recent recommendations.