Received: 26.06.2010 Accepted: 21.07.2010 J Gastrointestin Liver Dis September 2010 Vol.19 No 3, 295-202 Address for correspondence: Dr. Angelo Zullo Gastroenterologia ed Endoscopia Digestiva PTP Nuovo Regina Margherita Roma, Italy Email: zullo66@yahoo.it Cyclic Antibiotic Therapy for Diverticular Disease: a Critical Reappraisal Angelo Zullo 1 , Cesare Hassan 1 , Giovanni Maconi 2 , Gianpiero Manes 2 , Gianfranco Tammaro 3 , Vincenzo De Francesco 4 , Bruno Annibale 5 , Leonardo Ficano 6 , Luigi Buri 7 , Giovanni Gatto 8 , Roberto Lorenzetti 1 , Salvatore M. Campo 1 , Enzo Ierardi 4 , Fabio Pace 9 , Sergio Morini 1 1) Gastroenterology Unit, “Nuovo Regina Margherita” Hospital, Rome; 2) Dept. of Clinical Sciences, Division of Gastroenterology, “L. Sacco” University Hospital, Milan; 3) Gastroenterology Unit, “Sant’Eugenio” Hospital, Rome; 4) Section of Gastroenterology, Department of Medical Sciences, University of Foggia, Foggia; 5) Dept. of Digestive and Liver Diseases, University “La Sapienza”, Sant’Andrea Hospital Rome; 6) Department of Oncology, Division of General and Oncological Surgery, University of Palermo, Palermo; 7) Gastroenterology and Digestive Endoscopy Unit, “Cattinara’’ Hospital, Trieste; 8) Gastroenterology and Digestive Endoscopy Unit “Villa Soia” Hospital Palermo; 9) Gastroenterology, “Bolognini” Hospital, Seriate, Italy Abstract Different symptoms have been attributed to uncomplicated diverticular disease (DD). Poor absorbable antibiotics are largely used for uncomplicated DD, mainly for symptom treatment and prevention of diverticulitis onset. Controlled trials on cyclic administration of rifaximin in DD patients were evaluated. Four controlled, including 1 double-blind and 3 open-label, randomized studies were available. Following a long-term cyclic therapy, a signiicant difference emerged in the global symptoms score (range: 0-18) between rifaximin plus ibers (from 6-6.5 to 1-2) and ibers alone (from 6.7 to 2-3.8), although the actual clinically relevance of such a very small difference remains to be ascertained. Moreover, a similar global symptom score reduction (from 6 to 2.4) can be achieved by simply recommending an inexpensive high-iber diet. Current data suggest that cyclic rifaximin plus ibers signiicantly reduce the incidence of the irst episode of acute diverticulitis as compared to ibers alone (1.03% vs 2.75%), but a cost-eficacy analysis is needed before this treatment can be routinely recommended. The available studies have been hampered by some limitations, and deinite conclusions could not be drawn. The cost of a long-life, cyclic rifaximin therapy administered to all symptomatic DD patients would appear prohibitive. Key words Diverticular disease – therapy – symptoms – rifaximin – diverticulitis – haemorrhage. Diverticular disease symptoms: a puzzling interpretation Diverticular disease (DD) is a very common condition in western countries, and its incidence has greately increased in the last decades. It is well known that DD prevalence rises with age, being relatively infrequent (5-10%) in subjects younger than 40 years and present in as many as 50-66% of people older than age 80 years [1]. Although DD remains asymptomatic in a large part of subjects, nearly 20% of patients develop some symptoms during their life-time [2]. Different symptoms have been attributed to uncomplicated DD, such as abdominal pain, bloating, and changes in bowel habit (constipation and/or diarrhoea) [2]. However, such a symptoms combination may be indistinguishable from that of the irritable bowel syndrome (IBS), a condition that is also highly prevalent in western populations [3, 4]. In addition, several alterations recognized as a possible cause of symptoms in the colon of DD patients are equally encountered in IBS. These include abnormal colonic motility, visceral hypersensitivity, low-grade inlammation, and increased circulating levels of either substance P or vasoactive intestinal polypeptide (VIP) [5, 6]. Currently, there is no reliable test to discriminate whether symptoms are actually caused by presence of diverticula in the colon or by an underlying IBS. On one hand, it has been proposed that gastrointestinal symptoms may precede the onset of DD in a proportion of subjects and, on the other hand, it is still unclear why up to 80% of cases of DD patients remain asymptomatic despite the presence of diverticula in their colon [7]. Such uncertainty is further increased by the observation that IBS prevalence has increased in elderly people in the last decades. Moreover, a recent population- based study found a signiicant association between the two conditions, the risk of DD being 9.4-fold increased (95% CI = 5.8-15.1) in patients >65 years with IBS as compared to age-matched control subjects without IBS [8]. Therefore, the overlap between IBS and DD may be expected to be