Probiotics for the Treatment of Symptomatic Uncomplicated Diverticular Disease

Abstract

Changes in the colonic microbiota are critical to the pathogenesis of diverticular complications such as diverticulitis and peridiverticular abscesses. However, more subtle changes in microbiota composition may well be important to the more chronic manifestations of diverticulosis. Some studies have shown the presence of bacterial overgrowth in subgroups of patients with diverticular disease and recent studies, using molecular biology techniques, found an increase of proteobacteria and actinobacteria in patients with symptomatic uncomplicated diverticular disease (SUDD), compared with healthy controls. The use of probiotics to modulate intestinal microecology in SUDD appears therefore rational. Although several investigations evaluating the clinical efficacy of probiotics have been performed, no definitive results have yet been achieved, mainly due to the heterogeneity of the available studies. Most of the studies used probiotics in combination with poorly absorbed antimicrobials or anti-inflammatory drugs. In only 4 studies, there was a harm using probiotics alone, but only 1 was a placebo-controlled, double-blind trial. The analysis of the available evidence reveals a poor quality of the published studies, whose design was heterogeneous, with only 2 out of 11 trials being double-blind and randomized. Therefore, available data can only suggest a benefit of probiotics in SUDD, but do not allow any evidence-based definite conclusion. As a consequence, current guidelines state that there is insufficient evidence to recommend probiotics for symptom relief in patients with diverticular disease.

Management of colonic diverticular disease in the third millennium: Highlights from a symposium held during the United European Gastroenterology Week 2017

“…Due to the large heterogeneity of the studies, 9 the efficacy of probiotics in SUDD remains poor, since high-quality trials are few, with only two randomized, controlled investigations available. 102 Large, well-designed, clinical studies are therefore needed to provide a strong evidence for probiotic use in diverticular disease.…”

“…However, in general, the quality of the studies is poor or the outcomes and treatments heterogeneous, so that the results are difficult to compare and interpret. 9 In one small randomized, unblinded trial, use of a polymicrobial lysate (given orally 2 weeks a month for 3 consecutive months) was associated with a decreased risk of recurrence. 58…”

“…The recent clear demonstration of gut microbiota alterations in this condition 6 has expanded the therapeutic armamentarium to include gut-selective antibiotics 7 and anti-inflammatory drugs, 8 albeit more research is needed to establish the optimal regimen (daily dose and duration) of therapy. The use of probiotics 9 further extends the so-called ‘microbiota-directed therapies’, despite evidence of their efficacy still being low.…”

Diverticular Disease: a Gut Microbiota Perspective

“…Although the involvement of the intestinal microbiome in the pathophysiology of diverticular disease still shows several areas of uncertainty, microbiome-targeted strategies have been investigated in the treatment of acute episodes of diverticulitis or in their prevention [97]. The use of probiotics in diverticular disease has been reviewed by different authors without conclusive evidence on their capacity to modify the disease course, due to the poor quality and heterogeneity of the studies [98][99][100].…”

Course of the Diverticular Disease: What is changing?

“…Also based on presumptive dysbiosis, probiotics have been studied, with some benefit shown in trials involving bacterial strains such as Lactobacillus, Bifidobacterium infantis, and combination products such as VSL#3, but such trials have been small and uncontrolled. While we wait higher-quality evidence to support this approach [7] the microbiome is likely to be an important target for SUDD therapy in the next years.…”