Clin Colon Rectal Surg
DOI: 10.1055/s-0044-1791521
Review Article

The Emerging Role of the Microbiota and Antibiotics in Diverticulitis Treatment

Alexander Troester*
1   Department of Surgery, University of Minnesota, Minneapolis, Minnesota
,
Lauren Weaver*
1   Department of Surgery, University of Minnesota, Minneapolis, Minnesota
,
Cyrus Jahansouz
2   Division of Colon & Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
› Author Affiliations
Funding None.

Abstract

Diverticular disease is the leading cause of elective colon surgery. With a rising incidence in younger populations, it continues to pose a significant burden on the health care system. Traditional etiopathogenesis implicated an infectious mechanism, while recent challenges to this theory have demonstrated the microbiome playing a significant role, along with genetic predispositions and associations with obesity and diet. Therefore, the role of antibiotics in uncomplicated disease merits reconsideration. In this review, we aim to outline the current knowledge regarding antibiotics for diverticulitis treatment, broadly define the microbiome components, functions, and modifiability, and discuss newly proposed pathogenetic mechanisms for diverticular disease that incorporate information regarding the microbiome. Analytic techniques for microbiota characterization and function continue to advance at a rapid pace. As emerging technology advances, we will continue to elucidate the role of the microbiome in diverticular disease development.

Authors' Contributions

A. T. contributed to the project conception and design, as well as the drafting and editing of the manuscript. L. W. was involved in the project conception and design, along with drafting and editing the manuscript. C. J. participated in editing the manuscript and provided final approval.


* A. T. and L. W. equally contributed to this work.




Publication History

Article published online:
30 September 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid diverticulitis: a systematic review. JAMA 2014; 311 (03) 287-297
  • 2 Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg 2005; 140 (07) 681-685
  • 3 Peery AF, Crockett SD, Murphy CC. et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018. Gastroenterology 2019; 156 (01) 254-272.e11
  • 4 Etzioni DA, Cannom RR, Ault GT, Beart Jr RW, Kaiser AM. Diverticulitis in California from 1995 to 2006: increased rates of treatment for younger patients. Am Surg 2009; 75 (10) 981-985
  • 5 Warner E, Crighton EJ, Moineddin R, Mamdani M, Upshur R. Fourteen-year study of hospital admissions for diverticular disease in Ontario. Can J Gastroenterol 2007; 21 (02) 97-99
  • 6 Etzioni DA, Mack TM, Beart Jr RW, Kaiser AM. Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment. Ann Surg 2009; 249 (02) 210-217
  • 7 Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part II: lower gastrointestinal diseases. Gastroenterology 2009; 136 (03) 741-754
  • 8 Bollom A, Austrie J, Hirsch W. et al. Emergency department burden of diverticulitis in the USA, 2006-2013. Dig Dis Sci 2017; 62 (10) 2694-2703
  • 9 Peery AF, Shaukat A, Strate LL. AGA clinical practice update on medical management of colonic diverticulitis: expert review. Gastroenterology 2021; 160 (03) 906-911.e1
  • 10 Hall J, Hardiman K, Lee S. et al; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum 2020; 63 (06) 728-747
  • 11 Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004; 363 (9409): 631-639
  • 12 Parra-Blanco A. Colonic diverticular disease: pathophysiology and clinical picture. Digestion 2006; 73 (Suppl. 01) 47-57
  • 13 Strate LL, Morris AM. Epidemiology, pathophysiology, and treatment of diverticulitis. Gastroenterology 2019; 156 (05) 1282-1298.e1
  • 14 Daniels L, Philipszoon LE, Boermeester MA. A hypothesis: important role for gut microbiota in the etiopathogenesis of diverticular disease. Dis Colon Rectum 2014; 57 (04) 539-543
  • 15 Rezapour M, Ali S, Stollman N. Diverticular disease: an update on pathogenesis and management. Gut Liver 2018; 12 (02) 125-132
  • 16 Schieffer KM, Kline BP, Yochum GS, Koltun WA. Pathophysiology of diverticular disease. Expert Rev Gastroenterol Hepatol 2018; 12 (07) 683-692
  • 17 Mastoraki A, Schizas D, Tousia A. et al. Evaluation of molecular and genetic predisposing parameters at diverticular disease of the colon. Int J Colorectal Dis 2021; 36 (05) 903-910
  • 18 Hyoju SK, Adriaansens C, Wienholts K. et al. Low-fat/high-fibre diet prehabilitation improves anastomotic healing via the microbiome: an experimental model. Br J Surg 2020; 107 (06) 743-755
  • 19 Gaines S, van Praagh JB, Williamson AJ. et al. Western diet promotes intestinal colonization by collagenolytic microbes and promotes tumor formation after colorectal surgery. Gastroenterology 2020; 158 (04) 958-970.e2
  • 20 Christ A, Lauterbach M, Latz E. Western diet and the immune system: an inflammatory connection. Immunity 2019; 51 (05) 794-811
  • 21 Portolese AC, McMullen BN, Baker SK. et al. The microbiome of complicated diverticulitis: an imbalance of sulfur-metabolizing bacteria. Dis Colon Rectum 2023; 66 (05) 707-715
  • 22 Bhatia M, Mattoo A. Diverticulosis and diverticulitis: epidemiology, pathophysiology, and current treatment trends. Cureus 2023; 15 (08) e43158
  • 23 Berman LG, Burdick D, Heitzman ER, Prior JT. A critical reappraisal of sigmoid peridiverticulitis. Surg Gynecol Obstet 1968; 127 (03) 481-491
  • 24 Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med 2007; 357 (20) 2057-2066
  • 25 de Korte N, Unlü C, Boermeester MA, Cuesta MA, Vrouenreats BC, Stockmann HB. Use of antibiotics in uncomplicated diverticulitis. Br J Surg 2011; 98 (06) 761-767
  • 26 Gaber CE, Kinlaw AC, Edwards JK. et al. Comparative effectiveness and harms of antibiotics for outpatient diverticulitis : two nationwide cohort studies. Ann Intern Med 2021; 174 (06) 737-746
  • 27 Munie ST, Nalamati SPM. Epidemiology and pathophysiology of diverticular disease. Clin Colon Rectal Surg 2018; 31 (04) 209-213
  • 28 Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K. AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012; 99 (04) 532-539
  • 29 Isacson D, Smedh K, Nikberg M, Chabok A. Long-term follow-up of the AVOD randomized trial of antibiotic avoidance in uncomplicated diverticulitis. Br J Surg 2019; 106 (11) 1542-1548
  • 30 Humes DJ, Spiller RC. Review article: the pathogenesis and management of acute colonic diverticulitis. Aliment Pharmacol Ther 2014; 39 (04) 359-370
  • 31 Daniels L, Ünlü Ç, de Korte N. et al; Dutch Diverticular Disease (3D) Collaborative Study Group. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg 2017; 104 (01) 52-61
  • 32 Jaung R, Nisbet S, Gosselink MP. et al. Antibiotics do not reduce length of hospital stay for uncomplicated diverticulitis in a pragmatic double-blind randomized trial. Clin Gastroenterol Hepatol 2021; 19 (03) 503-510.e1
  • 33 Estrada Ferrer O, Ruiz Edo N, Hidalgo Grau LA. et al. Selective non-antibiotic treatment in sigmoid diverticulitis: is it time to change the traditional approach?. Tech Coloproctol 2016; 20 (05) 309-315
  • 34 Isacson D, Thorisson A, Andreasson K, Nikberg M, Smedh K, Chabok A. Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study. Int J Colorectal Dis 2015; 30 (09) 1229-1234
  • 35 Mali JP, Mentula PJ, Leppäniemi AK, Sallinen VJ. Symptomatic treatment for uncomplicated acute diverticulitis: a prospective cohort study. Dis Colon Rectum 2016; 59 (06) 529-534
  • 36 Sallinen VJ, Mentula PJ, Leppäniemi AK. Nonoperative management of perforated diverticulitis with extraluminal air is safe and effective in selected patients. Dis Colon Rectum 2014; 57 (07) 875-881
  • 37 Brochmann ND, Schultz JK, Jakobsen GS, Øresland T. Management of acute uncomplicated diverticulitis without antibiotics: a single-centre cohort study. Colorectal Dis 2016; 18 (11) 1101-1107
  • 38 Hjern F, Josephson T, Altman D. et al. Conservative treatment of acute colonic diverticulitis: are antibiotics always mandatory?. Scand J Gastroenterol 2007; 42 (01) 41-47
  • 39 Andersen JC, Bundgaard L, Elbrønd H, Laurberg S, Walker LR, Støvring J. Danish Surgical Society. Danish national guidelines for treatment of diverticular disease. Dan Med J 2012; 59 (05) C4453
  • 40 Andeweg CS, Mulder IM, Felt-Bersma RJ. et al; Netherlands Society of Surgery, Working group from Netherlands Societies of Internal Medicine, Gastroenterologists, Radiology, Health echnology Assessment and Dieticians. Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig Surg 2013; 30 (4–6): 278-292
  • 41 Kruis W, Germer CT, Leifeld L. German Society for Gastroenterology, Digestive and Metabolic Diseases and The German Society for General and Visceral Surgery. Diverticular disease: guidelines of the German Society for Gastroenterology, Digestive and Metabolic Diseases and the German Society for General and Visceral Surgery. Digestion 2014; 90 (03) 190-207
  • 42 Vennix S, Morton DG, Hahnloser D, Lange JF, Bemelman WA. Research Committee of the European Society of Coloproctocology. Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines. Colorectal Dis 2014; 16 (11) 866-878
  • 43 Fugazzola P, Ceresoli M, Coccolini F. et al. The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly. World J Emerg Surg 2022; 17 (01) 5
  • 44 Hawkins AT, Wise PE, Chan T. et al. Diverticulitis: an update from the age old paradigm. Curr Probl Surg 2020; 57 (10) 100863
  • 45 Lambrichts DPV, Birindelli A, Tonini V. et al. The multidisciplinary management of acute complicated diverticulitis. Inflamm Intest Dis 2018; 3 (02) 80-90
  • 46 Lee JY, Tsolis RM, Bäumler AJ. The microbiome and gut homeostasis. Science 2022; 377 (6601): eabp9960
  • 47 Berg G, Rybakova D, Fischer D. et al. Microbiome definition re-visited: old concepts and new challenges. Microbiome 2020; 8 (01) 103
  • 48 Lloyd-Price J, Mahurkar A, Rahnavard G. et al. Strains, functions and dynamics in the expanded Human Microbiome Project. Nature 2017; 550 (7674): 61-66
  • 49 Tropini C, Earle KA, Huang KC, Sonnenburg JL. The gut microbiome: connecting spatial organization to function. Cell Host Microbe 2017; 21 (04) 433-442
  • 50 Sundin OH, Mendoza-Ladd A, Zeng M. et al. The human jejunum has an endogenous microbiota that differs from those in the oral cavity and colon. BMC Microbiol 2017; 17 (01) 160
  • 51 Ley RE, Turnbaugh PJ, Klein S, Gordon JI. Microbial ecology: human gut microbes associated with obesity. Nature 2006; 444 (7122): 1022-1023
  • 52 Daniels L, Budding AE, de Korte N. et al. Fecal microbiome analysis as a diagnostic test for diverticulitis. Eur J Clin Microbiol Infect Dis 2014; 33 (11) 1927-1936
  • 53 Alam A, Leoni G, Quiros M. et al. The microenvironment of injured murine gut elicits a local pro-restitutive microbiota. Nat Microbiol 2016; 1: 15021
  • 54 Leoni G, Neumann PA, Sumagin R, Denning TL, Nusrat A. Wound repair: role of immune-epithelial interactions. Mucosal Immunol 2015; 8 (05) 959-968
  • 55 Shogan BD, Smith DP, Christley S, Gilbert JA, Zaborina O, Alverdy JC. Intestinal anastomotic injury alters spatially defined microbiome composition and function. Microbiome 2014; 2: 35
  • 56 Shogan BD, Belogortseva N, Luong PM. et al. Collagen degradation and MMP9 activation by Enterococcus faecalis contribute to intestinal anastomotic leak. Sci Transl Med 2015; 7 (286) 286ra68
  • 57 Yoo W, Zieba JK, Foegeding NJ. et al. High-fat diet-induced colonocyte dysfunction escalates microbiota-derived trimethylamine N-oxide. Science 2021; 373 (6556): 813-818
  • 58 Byndloss MX, Olsan EE, Rivera-Chávez F. et al. Microbiota-activated PPAR-γ signaling inhibits dysbiotic Enterobacteriaceae expansion. Science 2017; 357 (6351): 570-575
  • 59 Spees AM, Wangdi T, Lopez CA. et al. Streptomycin-induced inflammation enhances Escherichia coli gut colonization through nitrate respiration. MBio 2013; 4 (04) e00430-e13
  • 60 Zhu W, Miyata N, Winter MG. et al. Editing of the gut microbiota reduces carcinogenesis in mouse models of colitis-associated colorectal cancer. J Exp Med 2019; 216 (10) 2378-2393
  • 61 Cevallos SA, Lee JY, Tiffany CR. et al. Increased epithelial oxygenation links colitis to an expansion of tumorigenic bacteria. MBio 2019; 10 (05) e02244-e19
  • 62 Winter SE, Winter MG, Xavier MN. et al. Host-derived nitrate boosts growth of E. coli in the inflamed gut. Science 2013; 339 (6120): 708-711
  • 63 Zhu W, Winter MG, Byndloss MX. et al. Precision editing of the gut microbiota ameliorates colitis. Nature 2018; 553 (7687): 208-211
  • 64 Cevallos SA, Lee JY, Velazquez EM. et al. 5-Aminosalicylic acid ameliorates colitis and checks dysbiotic Escherichia coli expansion by activating PPAR-γ signaling in the intestinal epithelium. MBio 2021; 12 (01) e03227-e20
  • 65 Hughes ER, Winter MG, Duerkop BA. et al. Microbial respiration and formate oxidation as metabolic signatures of inflammation-associated dysbiosis. Cell Host Microbe 2017; 21 (02) 208-219
  • 66 Shin NR, Whon TW, Bae JW. Proteobacteria: microbial signature of dysbiosis in gut microbiota. Trends Biotechnol 2015; 33 (09) 496-503
  • 67 Kelly CR, Khoruts A, Staley C. et al. Effect of fecal microbiota transplantation on recurrence in multiply recurrent Clostridium difficile infection: a randomized trial. Ann Intern Med 2016; 165 (09) 609-616
  • 68 Staley C, Halaweish H, Graiziger C. et al. Lower endoscopic delivery of freeze-dried intestinal microbiota results in more rapid and efficient engraftment than oral administration. Sci Rep 2021; 11 (01) 4519
  • 69 Boatman S, Kaiser T, Nalluri-Butz H. et al. Diet-induced shifts in the gut microbiota influence anastomotic healing in a murine model of colonic surgery. Gut Microbes 2023; 15 (02) 2283147
  • 70 Nalluri-Butz H, Bobel MC, Nugent J. et al. A pilot study demonstrating the impact of surgical bowel preparation on intestinal microbiota composition following colon and rectal surgery. Sci Rep 2022; 12 (01) 10559
  • 71 Zullo A. Medical hypothesis: speculating on the pathogenesis of acute diverticulitis. Ann Gastroenterol 2018; 31 (06) 747-749
  • 72 Golder M, Burleigh DE, Belai A. et al. Smooth muscle cholinergic denervation hypersensitivity in diverticular disease. Lancet 2003; 361 (9373): 1945-1951
  • 73 Tursi A, Elisei W. Role of inflammation in the pathogenesis of diverticular disease. Mediators Inflamm 2019; 2019: 8328490
  • 74 Carter F, Alsayb M, Marshall JK, Yuan Y. Mesalamine (5-ASA) for the prevention of recurrent diverticulitis. Cochrane Database Syst Rev 2017; 10 (10) CD009839
  • 75 Picchio M, Elisei W, Brandimarte G. et al. Mesalazine for the treatment of symptomatic uncomplicated diverticular disease of the colon and for primary prevention of diverticulitis: a systematic review of randomized clinical trials. J Clin Gastroenterol 2016; 50 (Suppl. 01) S64-S69
  • 76 Stefanelli G, Viscido A, Valvano M. et al. Is mesalazine treatment effective in the prevention of diverticulitis? A review. Eur Rev Med Pharmacol Sci 2020; 24 (15) 8164-8176
  • 77 Iannone A, Ruospo M, Wong G. et al. Mesalazine for people with diverticular disease: a systematic review of randomized controlled trials. Can J Gastroenterol Hepatol 2018; 2018: 5437135
  • 78 Schieffer KM, Sabey K, Wright JR. et al. The microbial ecosystem distinguishes chronically diseased tissue from adjacent tissue in the sigmoid colon of chronic, recurrent diverticulitis patients. Sci Rep 2017; 7 (01) 8467