Editorial: Diverticulitis - A Neglected Disease Despite its Clinical Burden

Wolfgang Kruis^1,2*Antonio Tursi^1,2SAVVAS PAPAGRIGORIADIS³

• ¹Faculty of Medicine, University of Cologne, Cologne, Germany
• ²Universitat zu Koln, Cologne, Germany
• ³IASO General Hospital, Athens, Greece

Diverticulosis of the colon and its clinical feature, the Diverticular Disease (DD), are highly frequent events. Related symptoms and complications are a burden for patients as well as a challenge for health care systems. Diverticulitis is ranking among the ten most frequent GIdiagnosis in the USA, the annual incidence being approximately 180 per 100 000 people, resulting in approximately 200 000 hospital admissions annually (ranking place 6 of hospital admissions) and an estimated health care expenditure of more than $6.3 billion/year (1).Incidence and prevalence of DD both are worldwide increasing and in-hospital mortality approaches 7% (2).Apparently, the discourse on DD underscores the pressing need for advanced management strategies and new treatments. Though research in the field is active still more basic as well as clinical scientific work is urgently needed. Pathogenesis and pathophysiology of DD remain not completely understood. On the basis of genetic predisposition, lifestyle, particularly in western environment, have been considered as key factors. But still important questions are not clear such as the impact of low-grade inflammation or factors leading from asymptomatic diverticulosis to symptomatic uncomplicated DD (SUDD) and acute diverticulitis (AD) (3). This special issue collects several studies covering different aspects of DD.Two studies have been conducted in the setting of SUDD. The first study, conducted in Japan, focused its attention on the potential role of bile acids (BAs) in the pathogenesis of SUDD.Authors found that fecal BA concentrations were significantly increased in patients with SUDD compared with controls, suggesting that fecal BAs might be involved in the pathogenesis of SUDD, and that controlling fecal BA levels may be therapeutic for SUDD (doi: 10.3389/fmed.2025.1533644.). The second study, conducted in Italy, focused its attention on the role of a post-biotic, the sodium butyrate, in modulating gut microbiota (GM) expression, and in managing SUDD symptoms. Using a micro-encapsulated and colonic-release formulation, authors found that sodium butyrate is able both in reducing proinflammatory bacterial taxa, and in improving abdominal pain (doi: 10.3389/fmed.2025.1487892.).Two studies arising from Greece focused their attention on the AD setting. In the first, authors discussed on the current and evolving surgical treatment for the complicated disease (doi: 10.3389/fmed.2025.1501734.); in the second, the same author discussed on the setting fistulating diverticulitis. Analyzing histopathology and epidemiological characteristics, authors proposed and interesting point of view about the need to consider this phenotype of DD as a distinct clinical entity rather than a simple complication of the disease (doi: 10.3389/fmed.2025.1500053. ).The last study is an interesting case report from Romania, in which the authors reported an unusual case of jejunal diverticulitis (doi: 10.3389/fmed.2024.1413254.).These studies explores new ways on the pathogenesis and the treatment of this neglected disease. About the role of BAs, we know that increased levels of fecal BAs, especially secondary BAs, have been reported to induce intestinal inflammation and diarrhea (4). The study from Jono et al (doi: 10.3389/fmed.2025.1533644.) found interesting findings: 1. there is no enhanced production of BAs in SUDD, but high level are detected in feces of SUDD patients;2. also calprotectin levels are detected, linked to the fecal BAs levels. This could occur due to some abnormality of the ileal BA transporter that causes a decrease in BA absorption and an increase in BA levels in the colon. This study suggest therefore that BAs malabsorption may cause low-grade inflammation being therefore a contributing factor for GM imbalance and symptoms' occurrence in these patients. In this way, the second study conducted in the same setting of patients opens a new therapeutic prospective. We know that butyrate, a short-chain fatty acid (SCFA), is an important energy source for colonocytes, regulates motility, pH and blood flow, improves mucosal barriers, and exerts significant anti-inflammatory and antimicrobial properties (5). The study from the Tursi et al (doi: 10.3389/fmed.2025.1487892.)shows two finding of interest: 1. butyrate works better in patients with more severe GM imbalance, improving significantly its alpha-and beta-diversity; 2. abdominal pain improvement is strictly linked to the efficacy of butyrate. In other words, SUDD patients having more severe abdominal pain, have higher GM imbalance, and respond better to butyrate supplementation. This means that, enhancing the metabolism of the colonocytes by butyrate supplementation, we could influence not only the restoration of more health GM, but also modulate the other factors involved in the pathophysiology of the disease (such as visceral hypersensitivity and low-grade inflammation) (3).The new information about the pathogenesis of the disease could also influence the surgical management of the disease. This means that not only the surgical techniques are evolving towards less invasive and more patient-focused techniques (doi: 10.3389/fmed.2025.1501734.), but also that specific disease's phenotypes, such as fistulating diverticulitis, must be revised according to the new evidences. In example, we know that Crohn's disease (CD) and diverticulitis of the colon share several characteristics (same tendency to fibrosis, same expression of some pro-fibrotic cytokines) (6). If also fistulating diverticulitis seems to have pathology features very close to that of CD (granulomatous inflammation and granulomatous vasculitis with mural lymphoid aggregates; non-necrotizing granulomatous inflammation situated at the outer edge of the muscularis propria; active vasculitis with transmural lymphoplasmacytic inflammation) (7,8), this means that, in the next future, also surgical techniques currently adopted for CD (9) could be applied to this phenotype of diverticulitis.Surgical approach that remains, unfortunately, the main therapeutic approach to jejunal diverticulitis due to its rare occurrence and its nonspecific symptoms (doi: 10.3389/fmed.2024.1413254.).In summary, this Special Issue shows that there is significant progress in understanding the causes of the disease and management of these patients. In view of the epidemiological importance, more clinical research is deserved to further refine patient care.