Why Does Diverticulitis Keep Returning?

How Common Is Recurrent Diverticulitis?

After a first episode of diverticulitis, the chance of having another episode at some point is roughly 25–35%. Put the other way: the majority of people who have one episode will never have another. But a significant number will — and of those, some will go on to have further episodes, each one potentially with a slightly higher risk of complications than the last.

The pattern varies enormously between people. Some have mild episodes years apart and manage them easily at home. Others have more frequent or more severe attacks that start to genuinely affect their work, relationships, and quality of life. Knowing what factors push people toward the higher-risk end gives you something to act on.

Why Does Diverticulitis Recur?

When you recover from diverticulitis, the diverticula (the small pouches) stay in your bowel wall — they do not go away. The same weak points that allowed the first episode to happen are still there. Whether or not another episode occurs depends partly on things you cannot change (like how many pouches you have), and partly on things you can (like your diet, your weight, and certain medications).

The key modifiable risk factors — the ones worth actively working on — include:

• Excess body weight: Carrying too much weight, especially around the middle, is one of the strongest modifiable risk factors for recurrence. It increases inflammation throughout the body, raises pressure inside the abdomen and colon, and alters the bacteria in the gut. People with a BMI over 30 have noticeably higher recurrence rates.
• Being physically inactive: Regular exercise helps the bowel move more quickly and with less pressure. Sitting for most of the day has the opposite effect.
• Not enough fibre: A low-fibre diet produces small, hard stools that require the bowel to squeeze much harder to move them along. That high pressure, applied to already weakened pouches, is what triggers inflammation. A high-fibre diet is the most evidence-backed dietary change for reducing recurrence.
• Smoking: Smoking impairs the immune system and promotes body-wide inflammation, and it is consistently linked with higher rates of diverticular complications including recurrence.
• Regular use of anti-inflammatory painkillers (NSAIDs): Medications like ibuprofen, naproxen, aspirin, and diclofenac taken regularly are consistently associated with higher rates of diverticulitis and diverticular bleeding. If you rely on these for pain, talk to your GP about whether paracetamol or another alternative could work instead.
• High red meat intake: Eating a lot of red meat — especially processed red meat — has been linked to higher diverticulitis risk in large population studies. The reason is not fully understood, but effects on the gut bacteria and inflammation pathways are likely involved.
• Heavy alcohol use: Moderate to heavy alcohol consumption is associated with a higher risk of diverticular complications.

Steps to Reduce Your Risk of Another Episode

Does Each Episode Become More Severe?

This is a worry many people have, and the honest answer is: not necessarily. The old teaching was that each episode was worse than the last. More recent research has actually shown that your first episode carries the highest risk of complications — partly because subsequent episodes produce scar tissue that may actually provide some structural protection against the pouches perforating (bursting).

That said, recurrent episodes do cause cumulative wear on the bowel wall. Over time, this can lead to chronic low-grade symptoms, scarring that narrows the bowel (called a stricture), or a fistula — an abnormal track between the bowel and another organ like the bladder. Repeated hospital stays, multiple courses of antibiotics, and the constant background worry of not knowing when the next attack will come all take a real toll on your quality of life. This is one of the main reasons elective surgery is offered to people with frequent recurrences — not because each episode is necessarily worse, but because the cumulative burden becomes too high.

Chronic Symptoms Between Episodes

Some people with diverticular disease develop a pattern of chronic, low-grade left lower abdominal pain and irregular bowel habit that persists between acute episodes — not a full-blown attack, but a constant background grumble. This is sometimes called symptomatic uncomplicated diverticular disease (SUDD), or in some cases post-diverticulitis IBS (because it can look and feel very similar to irritable bowel syndrome). It may be related to ongoing low-level inflammation, changes in how the bowel moves, or alterations in the gut bacteria after repeated episodes.

SUDD can be genuinely draining to live with. The mainstay of treatment remains a high-fibre diet and regular exercise. A medication called rifaximin — a type of antibiotic that stays mostly in the gut — has some evidence for controlling symptoms and is typically given in short intermittent courses. Mesalazine (usually used in inflammatory bowel disease) has also been tried with modest benefit. For people with troublesome chronic symptoms who are not getting enough relief from these measures, elective surgery — removing the affected section of bowel — can provide lasting relief.

When Surgery Is the Better Option

For some people with recurring or chronic diverticulitis, elective sigmoid colectomy — removing the section of bowel where the diverticula are causing problems — offers the best chance of real, lasting relief. Surgery is not without risk, but for the right person and in the right circumstances, it is a one-time solution that removes the ongoing cycle of attacks and recoveries.

Surgery tends to come into serious consideration when:

• You have had two or more episodes that needed hospitalisation — especially if the episodes are becoming more frequent, more disruptive, or harder to treat
• You have chronic symptoms between episodes that are significantly affecting your daily life or quality of life
• You have had a complicated episode — such as an abscess or a fistula — even if it was just the one time
• You are younger (under 50), with many years ahead of potential recurrence if surgery is not done
• You are on immunosuppressant medication, which makes future episodes more dangerous and less predictable

Read more in our detailed article: Do I need surgery for diverticulitis?

The Role of Follow-Up After an Episode

After recovering from a first episode, follow-up is important — not just for peace of mind, but because missing this step can mean missing a serious diagnosis. Most guidelines recommend:

• A colonoscopy six to eight weeks after you have fully recovered — this is to rule out bowel cancer, which can occasionally look very similar to diverticulitis on a CT scan. It also gives a clearer picture of the extent of your diverticular disease.
• A follow-up conversation with your GP or specialist about lifestyle changes and diet — and whether there are any further investigations worth doing based on your individual situation
• A referral to a colorectal surgeon if you are worried about future episodes, or if you want to understand your options including surgery

Please do not skip the colonoscopy follow-up. It is a short, well-tolerated procedure and it could catch something important.

Gut Microbiome and Recurrence

Researchers are increasingly interested in the role of the gut microbiome — the community of bacteria living in your bowel — in diverticulitis. People with recurrent diverticulitis tend to have less bacterial diversity, fewer of the beneficial bacteria (like Lactobacillus and Bifidobacterium), and more of certain pro-inflammatory species. Whether this is a cause or a consequence of recurrent infection is still being worked out.

This is a genuinely active area of research. For now, the most practical thing you can do to support a healthy gut microbiome is dietary: eat plenty of fibre (which feeds the good bacteria), include fermented foods like live yoghurt, kefir, or sauerkraut in your diet, and avoid unnecessary antibiotics where possible. As for probiotic supplements — the research is promising but not yet definitive enough for a firm recommendation. They are safe, and they are a reasonable addition, but they are not a replacement for the dietary basics.

Frequently Asked Questions