Diverticular disease

Diverticular disease occurs when pouches (diverticula) in the intestine, usually the large intestine or colon, become inflamed. Most diverticula occur in the sigmoid colon, the curved part of the large intestine closest to the rectum, and they tend to become more numerous as we age.

Diverticulosis is the presence of many diverticula along the intestinal wall. It occurs more commonly as people get older and in countries such as the U.S. where the diet is generally low in fiber. It is a fairly common condition. More than 50% of adults over the age of 60 have diverticula, and it may not cause any symptoms.

Diverticulitis occurs when one or more diverticula become inflamed. The inflammation may be local (just in the area of the diverticulum), or may spread to the abdominal lining (peritoneum), called peritonitis. Small (microscopic) or large perforations (holes in the intestinal wall) occur in 15 - 20% of people who have diverticula.

Signs and Symptoms

Often diverticula cause no symptoms, although you may experience irregularities in bowel habits. If symptoms do appear, they may include the following:

• Abdominal pain, especially pain low on the left side of the abdomen after a meal
• Either painless rectal bleeding or passing of blood in stool
• Fever
• Nausea
• Vomiting
• Irregular bowel movements including constipation or diarrhea
• Gas

Some people with diverticulitis develop fistulas, or abnormal passageways from the intestines into the abdomen or to another organ such as the bladder. This may lead to a urinary tract infection, gas in the urine, pain while urinating, or a more frequent need to urinate.

Some people develop peritonitis, an inflammation of the lining of the abdomen. Symptoms of peritonitis may include sudden abdominal pain, muscle spasms, guarding (involuntary contraction of muscles to protect the affected area), and possibly sepsis, the term for an infection that has spread to the blood. Peritonitis is a serious condition that can be life-threatening if not treated.

What Causes It?

The cause of diverticular disease is unknown, but several factors may contribute to changes in the wall of the colon. These include aging, the movement of waste through the colon, changes in intestinal pressure, a low-fiber diet, and physical abnormalities.

Who's Most At Risk?

These factors increase the risk for developing diverticular disease:

• Low-fiber diet
• Advanced age
• Obesity
• Male gender, for diverticulitis

The following may contribute as well:

• High fat intake
• Lack of regular physical activity

What to Expect at Your Provider's Office

Your health care provider will examine your abdomen for tenderness, swelling, and guarding and may try to detect any unusual mass around the intestines. Yor health care provider may also test your blood, urine, and stool for signs of infection or blood. A computed tomography (CT) scan, ultrasound, and other imaging techniques may help locate diverticula and any inflammation, fistulae, abscesses, or other abnormalities.

Treatment Options

Prevention

To help prevent diverticular disease:

• Eating a high-fiber (15 g of fiber per day), low-fat diet that contains lots of vegetables may lessen the risk of diverticular disease. Such a diet is also beneficial for overall health and may reduce the risk of heart disease and cancer, too.
• Avoid red meat.
• If you have diverticula, avoid foods such as seeds that may block the opening of a diverticulum and lead to inflammation.
• Exercise regularly.

Treatment Plan

For mild symptoms, your health care provider may recommend a clear liquid diet and prescribe antibiotics. More serious cases may require hospitalization, intravenous (IV) feeding to rest the intestine, IV antibiotics, and IV antispasmodics, which relax the intestine. Eating a high-fiber diet and taking psyllium supplements may help following an attack.

For repeated attacks, your doctor may recommend surgery to remove the part of the colon that is affected. Those who have severe complications, or whose condition becomes worse within a day or two of an attack, may need surgery right away.

Drug Therapies

Your doctor may prescribe antibiotics to fight infection, antispasmodics to relieve cramping, and analgesics to relieve pain.

Surgical and Other Procedures

If the condition is severe or leads to complications, or if attacks recur, a health care provider may recommend removing part of the colon.

Complementary and Alternative Therapies

Nutrition plays an important role in preventing and treating gastrointestinal disease, especially diverticulosis. You may help minimize attacks and improve treatment results by following some specific recommendations about your diet.

Nutrition and Supplements

Eat a diet that is high in fiber (15 g per day). Food is the best source of fiber. One study suggested that the following foods were associated with a lower risk of diverticular disease: cucumber, lettuce, spinach, and brown bread. You may also use fiber supplements to increase the amount of fiber you take in every day. Common kinds of fiber supplements include insoluble fiber supplements such as psyllium and glucomannan (3 - 5 g per day of either supplement). Your doctor may also suggest soluble fiber supplements such as flax seed and oat bran, which can be less irritating than insoluble supplements. Talk to your doctor to find the right combination for you.

Glutamine (400 mg four times per day, between meals) is an amino acid found in the body that helps the intestine function properly. While there is no evidence that glutamine specifically helps reduce symptoms of diverticular disease, it may be beneficial for overall intestinal health. Do not take glutamine if you are diabetic or have seizures.

Omega-3 fatty acids, such as those found in fish oil, may help fight inflammation. (On the other hand, omega-6 fatty acids, found in meats and dairy products, tend to increase inflammation.) For a condition such as diverticulitis, it may be wise to eat a diet rich in omega-3 fatty acids, or take a supplement (1,000 mg one to two times per day). This type of diet may also help prevent colon cancer. Do not take high doses of a fish oil supplement if you are on blood-thinning medication.

Probiotics, such as Lactobacillus acidophilus, Lactobacillus plantarum, Saccharomyces boulardii (250 mg, taken one time per day between meals) and bifidobacteria, help maintain the health of the intestines.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

The following herbs are often used to treat gastrointestinal illness:

• Flaxseed (Linum usitatissimum) may be helpful in treating diverticulosis. It contains fiber and works as a bulk-forming laxative, softening stool and speeding transit time through the intestine. Use ground flaxseed, 15 g per day. Do not take flaxseed if you take blood-thinning medication or have diabetes.
• Slippery elm (Ulmus fulva) is a demulcent (protects irritated tissues and promotes their healing). Take 60 - 320 mg per day. One tsp. powder may be mixed with water and drunk three to four times a day.
• Cat's claw (Uncaria tomentosa, 250 mg per day) is an anti-inflammatory.
• Wild yam (Dioscorea villosa, 2 - 4 g per day in two or three divided doses). Do not take wild yam if you have or are at risk of having breast cancer, prostate cancer or any hormonally influenced condition.
• Marshmallow (Althaea officinalis) is a demulcent and emollient. Drink one cup of tea three times per day. To make tea, steep 2 - 5 g of dried leaf or 5 g dried root in one cup boiling water, strain, and cool. Avoid marshmallow if you have diabetes.
• Chamomile (Matricaria recutita), one to three cups of tea per day. To make tea, steep 3 g flower heads in one cup boiling water, strain, and cool.
• Licorice (Glycyrrhiza glabra, 380 - 1,140 g per day) can reduce spasms and inflammation in the gastrointestinal tract. Do not take licorice for a long period of time or if you have high blood pressure or heart failure. Look for products that say they contain mostly DGL, which has the majority of the blood-pressure raising component of licorice removed.

Homeopathy

While there have been few studies examining the effectiveness of specific homeopathic remedies, professional homeopaths may recommend one or more of the following treatments for diverticular disease based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

• Belladonna -- used for abdominal pain and cramping that comes on suddenly and feels better with firm pressure. It is particularly helpful if constipation accompanies the pain.
• Bryonia -- used for abdominal pain that worsens with movement and is relieved by heat. It is particularly useful if vomiting or constipation with dry, hard stools accompanies the pain.
• Colocynthis -- used for sharp, cramping abdominal pains that improve with pressure. It is particularly useful if pain is accompanied by restlessness and diarrhea.

Acupuncture

Acupuncture may help relieve pain and other symptoms. Acupuncturists treat people with diverticular disease based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. Acupuncture and Chinese medicine in general can be used to promote gastrointestinal health.

Following Up

If you develop a fever, tenderness in the abdomen, or bleeding from the rectum or in the stool, alert your health care provider right away. You may be hospitalized for a fever higher than 101°F, worsening symptoms, signs of peritonitis, or increased white blood cell count found in laboratory tests.

Prognosis/Possible Complications

About one-third of those who develop diverticulitis have a second episode, and of this group, half generally have a third attack. Twenty percent of patients develop complications after the first attack, 60% after a second attack. Complications may include:

• An abscess (pocket of pus)
• Blocked intestine
• A perforation (hole) in the intestine leading to peritonitis, sepsis, and even shock
• Fistulas, which may also lead to sepsis
• Bleeding

Those who have experienced bleeding once are at high risk for developing bleeding again.

Supporting Research

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Ambrosetti P, Robert JH, Witzig JA, et al. Acute left colonic diverticulitis: a prospective analysis of 226 consecutive cases. Surgery. 1994;115(5):546-550.

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