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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:

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:

The following may contribute as well:


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:

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:

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.

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:

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


Supporting Research

Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC. A prospective study of alcohol, smoking, caffeine, and the risk of symptomatic diverticular disease in men. Ann Epidemiol. 1995;5(3):221-228.

Aldoori W, Ryan-Harshman M. Preventing diverticular disease. Review of recent evidence on high-fibre diets. Can Fam Physician . 2002 Oct;48:1632-7.

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.

Blumenthal M, Goldberg A, Brinckmann J, eds. Herbal Medicine: Expanded Commission E Monographs . Newton, Mass: Integrative Medicine Communications; 2000:134-138, 314-321.

Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of Internal Medicine . 14th ed. New York, NY: McGraw-Hill; 1998.

Feldman M, ed. Sleisenger & Fordtran's Gastrointestinal and Liver Disease . 6th ed. Philadelphia, Pa: W.B. Saunders; 1998.

Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med . 1998;338(21):1521-1526.

Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg . 1978;12:85-109.

Kohler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. Surg Endosc . 1999;13(4):430-436.

Manousos O, Day NE, Tzonou A, et al. Diet and other factors in the aetiology of diverticulosis: an epidemiological study in Greece. Gut. 1985;26(6):544-549.

Murray M. Encyclopedia of Nutritional Supplements . Rocklin, Calif: Prima Publishing; 1996:315.

Nair P, Mayberry JF. Vegetarianism, dietary fibre and gastro-intestinal disease. Dig Dis . 1994;12(3):177-185.

O'Keefe SJ. Nutrition and gastrointestinal disease. Scand J Gastroenterol Suppl . 1996;220:52-59.

Sabiston DC, Lyerly HK, eds. Textbook of Surgery . 15th ed. Philadelphia, Pa: W.B. Saunders; 1998.


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