Managing Diverticular Disease
I am not a doctor, and this publication is provided for informational purposes
only.
Diverticular disease, Diverticulosis and
Diverticulitis What is the difference?
This disorder is characterized by the development of
pockets or ‘diverticula’ within the colon wall. These diverticula tend to
develop in the weak areas of the bowel, in particular, sites where a large
number of bloods vessels penetrate the walls of the bowel and in areas that are
generally narrower than most others- such as the sigmoid colon.
It is believed that the development of diverticula is
a result of the adoption of western diets, which tend to be low in fiber.
This is evident in developed or industrialized
countries. Due to the large amounts of refining within the food system, the
amount of fiber contained in many foods is severely diminished. A diet low in
fiber results in the production of stools of a different consistency than
normal. This consistency requires more pressure to be present in order to move
the stools through the bowel. It is the high pressures that result in the bowel
expanding or ‘pocketing outwards through the surrounding muscle, consequently forming
the pocket like structures known as diverticula.
Diets high in beef and animal products as opposed to
fruit and vegetable are also shown to result in diverticular disease. Animal
products contain very little fiber, whereas plants are the main supply for
fiber in the diet. If you limit the amount of fruit and vegetables you consume,
you limit the amount of fiber in your diet, and
increase the pressure in your bowels. This puts you in a high risk
category for developing diverticula.
Studies have shown that diets high in vegetables, such
as those in developing countries, decrease the chances of developing
diverticular disease.
There may also be a genetic component affecting the
development of diverticular disease. This suggests that raised pressure in the
bowel may be hereditary.
Another factor associated with diverticular disease is
age. Diverticular disease is commonly found in individuals over the age of
forty. It is estimated that one third of the population at forty years of age
and two thirds of the population at eighty years of age have diverticular
disease.
Individuals already suffering form colonic mobility
problems or from defects in the strength of the colon wall are also at risk of
developing diverticular disease. When sections of the colon don't work
effectively, pressure builds up and can lead to the development of diverticula.
Generally, the condition does not discriminate by race
or gender. It seems to affect people within the same culture. For example, if
an Oriental moves to a western culture and adopts the western habits and diet,
they become as susceptible to the disease as the rest of the culture.
Conversely, if someone from the western culture, moves
to an Oriental culture and adopts the culture and eating habits, their chances
of developing the disease diminishes dramatically.
The term diverticula disease is an overall description
of the condition, and encompasses the two phases of the disease, diverticulosis
and diverticulitis.
Diverticulosis: This term
refers to the presence of diverticula (pockets) within the colon. A person with
diverticulosis may have no symptoms and it is possible that they may never
develop the active phase of the condition.
Diverticulitis: This term
describes the active phase of the disease, in which the diverticula become
inflamed. The current belief is, diverticulitis occurs when body fluids or
faecal matter becomes trapped in the diverticula. This creates a perfect
environment for bacteria to grow and cause infection. The infection may proceed
in one of four ways.
1)
The infection may spontaneously resolve itself without
medical intervention.
2)
The infection may progress, leading to more serious
complications
3)
The infection may cause partial or complete
obstruction of the bowel. This generally must be addressed with surgery.
4)
The infection may fistulize. If the infection is not
treated, the site of infection will spread and consequently break through to
another organ or cavity of the body, creating a tunnel or fistula.
Diverticulitis does not occur in every individual with
diverticulosis. Only a small proportion of those with diverticulosis will
develop diverticulitis.
Diverticular disease can be diagnosed in one of
several ways:
1) Colonoscopy: This procedure involves a thin,
lighted tube being passed through the rectum in order for a doctors to obtain a
thorough look at the bowel wall. This also enables the removal of small pieces
of the bowel wall for further investigation via biopsy.
2) Single Contrast Barium Enema: A thin
tube is inserted through the rectum in order to feed a white liquid known as
barium into the bowel. The presence of the barium allows for the outline of the
walls of the bowel to show in an x-ray. If over activity due to presence of the
disease is prevalent, the bowel wall will appear thickened.
3) Double Contrast Barium Enema: If it is
believed that an individual may have diverticular disease, an enema may be
implemented to view the wall of the colon. The double contrast enema is more
accurate than a single contrast enema.
An enema is not used if there is any possibility of
diverticulitis as this may increase the risk of perforation of the diverticula.
4) Computerised Tomography (CT) Scan: This
procedure is less invasive than the aforementioned because it does not require
a tube to be inserted through the rectum. Instead, a scan is used to produce a
3D image on a computer screen where the bowel can be viewed. Ct scans are used
due to the high degree of accuracy in diagnosing diverticula disease and
identifying the development of abscesses.
5) Water-soluble contrast enema: Another form
of enema enables imaging of the intraluminal space and consequent diagnosis of
diverticular disease.
6) Ultrasonography: This test is equally as
accurate and non-invasive as a CT scan in diagnosing acute colonic
diverticulitis. Ultrasonography involves the use of a skin probe that emits
sound waves. These sound waves produce echoes which form a picture of organs
and tissues inside the body on an ultrasound machine.
For those diagnosed with diverticular disease, many
will find that their diverticula will not cause any problems and they never
develop the active phase of the disorder. Some may develop this phase once and
recover very quickly form the event with treatment through optimal diet and
antibiotics. Approximately ten to twenty percent of those with diverticulosis
will develop the active phase of the disease.
The symptoms of diverticular disease
Many individuals who develop diverticular disease will
not display symptoms. In the small percentage of individuals who do show
symptoms, the following may occur:
1) Diarrhoea:
Diarrhoea is characterised by large, frequent, watery bowel movements. Constant
loss of fluid via diarrhoea may lead to dehydration. If this symptom is severe,
replenishing of fluids is necessary. If this cannot be done at home, the person
may require hospitalisation.
OR
2) Abdominal Pain or cramps:
Abdominal pain is the most common symptom of diverticulitis and tends to be a
tenderness around the lower left side of the abdomen. This is typically
indicative of inflammation of the diverticula due to infection.
3) Abdominal
Bloating: This symptom is characterised by feelings of tightness and
fullness within the abdominal area and is usually due to a build up in pressure
or gas.
5)
Nausea: The feeling of having to vomit.
6)
Vomiting: Throwing up. Vomiting generally
follows nausea.
7)
Fever: A condition marked by elevated
temperatures, sweating, cold clammy hands and in extreme circumstances the
individual may become delirious.
9) Polyuria,
Dysuria and Pyuria:
a. Polyuria: An
increase in the frequency of urination.
b. Dysuria: Pain
while urinating.
c. Pyuiria: The
presence of pus or white blood cells in the urine. The urine is cloudy if pus
is present.
These symptoms
occur if the bladder or ureters have been irritated in someway due to the
presence of inflamed diverticula.
The severity of any of these symptoms is dependent on
the degree of inflammation and extent of infection of the diverticula.
If a person is experiencing any of the aforementioned
symptoms, a visit to the doctor would be recommended. Self-diagnosing is not
wise as these symptoms are similar to those of other gastro-intestinal
disorders.
Most doctors will treat these acute symptoms with a
course of antibiotics and a liquid diet until the diverticula cease to be
inflamed.
Complications of
diverticular disease
Without the correct treatment,
serious cases of diverticular disease can lead to:
1) Infection: Infection occurs when
bodily fluids or faeces become trapped in the diverticula and begin to
stagnate. This provides an optimal environment for the growth of bacteria and
consequently, the development of infection.
2)
Rectal Bleeding: Bleeding from
the rectum can occur if diverticula present in the colon begin to bleed due to
the bursting of a blood vessel.
Rectal bleeding will present itself
in one of two ways:
a) Small amounts of blood will be present in
the stool over a few days. This generally rectifies itself.
b) A large amount of blood is produced over a
small amount of time, due to the bursting of a blood vessel. The onset of this
type of bleeding is generally painless, immediate and accompanied by the urge
to defecate. This symptom is usually only present in those with extreme cases
of diverticulitis and requires hospitalisation and possible surgery.
Alternatively, the implementation of a device up through the rectum to
cauterise the bleeding wound shut. In some cases, the bleeding may stop
spontaneously without the requirement of medical intervention.
3)
Haemorrhage: The presence of
rectal bleeding or bloody stools is generally indicative of internal bleeding
or haemorrhage. Internal haemorrhaging will present itself as red or burgundy
coloured stools.
4) Fistulas: A fistula is an abnormal
tunnel or connection between two organs that develops as a result of infection.
In the case of diverticulitis this infection is present with the inflamed
diverticula.
a)
Enterocutaneous: Pathway leading
form the gut, to the area of infection and finally to the skin.
b)
Enteroenteric: Any fistula
involving the intestines.
c)
Enterovaginal: A fistula
creating a pathway to the vagina. Symptoms of this fistula include vaginal
discharge containing faecal matter. Feculent vaginal discharge can also be a
result of a fistula developing between the sight of infection and the uterus.
d)
Enterovesicular: A fistula
creating a pathway form the site of infection to the bladder. Symptoms of the
development of this type of fistula include frequent urinary tract infections,
pneumaturia and the passing of gas from the urethra during urination.
In diverticular disease, the
resultant fistulas are generally faecal or anal fistulas, meaning the fistula
may cause faeces to pass through openings other than the anus. Fistulas are
formed from abscesses which do not have a chance of healing due to being
constantly filled with bodily fluids or stools. If these abscesses remain
untreated they will consequently break through to the skin or another organ,
creating a tunnel or connection between the two structures.
a)
Blind fistulas- only one end of the fistula has an
opening
b) Complete fistula- Both ends of the fistula
are open
c) Horseshoe fistula- the anus is connected
to the surface of the skin via a tunnel around the rectum.
d) Incomplete fistula- is only attached to
one organ, generally the skin.
Symptoms of a fistula include pain,
feeling ill, fever, tenderness or itching and severity will range depending on
the location of the fistula itself.
5) Large Bowel Obstruction: This
complication only occurs in a small number of individuals suffering from
diverticulitis. As a result of the swelling due to inflammation scar tissue
develops. Blockage due to inflammation will settle as the inflammation is
treated, however blocking due to scar tissue remains. These blockages can occur
as partial or total blockages. Partial blockages are not urgent, and therefore
corrective surgery can be planned. Total blockages are urgent and must be
addressed via surgery immediately.
6) Development of an Abscess: These are
pus filled areas of infection and may form if initial infection remains
untreated.
Due to the destruction of tissue by an
abscess, small holes known as perforations allow the leakage of pus out of the
colon into the abdominal area. Perforations may cause the individual to develop
pain in the back or lower extremities.
If excessive amounts of infection
leak out of the contaminated area into the abdominal cavity, peritonitis may
occur. In this case, the individual will begin experiencing severe, generalised
abdominal pain. Peritonitis refers to the infection of the walls of the abdomen
and requires immediate surgery to clean the abdomen. Peritonitis can be fatal
without treatment. Treatment involves an operation to clean the abdomen and
infected parts of the colon are removed.
Dietary Management of Diverticular disease
All current literature recommends that the most
effective way to prevent or manage diverticulosis is a high fibre diet.
Fibre is the indigestible portion of plant foods which
aids in bulking up the stool to assist it in passing through the body to assure
regular bowel movements.
There are two types of fibre in the diet, soluble and
insoluble fibre. Both aid in the creation of a stool and prevent constipation.
1) Soluble
fibre: dissolves easily in water and takes on a soft texture in the
intestines. This fibre is the body's main means of bulking the stool.
2) Insoluble
fibre: passes through the gastro-intestinal tract virtually unchanged.
As plant materials are passed through the body, the
removal of water, protein, fats, carbohydrates and essential nutrients occurs.
Upon entering the colon, all that remains to be
digested is water. The colon should remove this remaining water, thus forming
the stool.
If an individual is not eating sufficient amounts of
food containing fibre, a very dry, hard stool is produced. Stools of this
consistency have difficulty moving through the bowel and require higher amounts
of pressure to be passed through. Gradually the body becomes incapable of
creating these high amounts of pressure, and begins to rely on the force of the
movement of the abdominal walls to transport stools through the bowel. This is
known as straining, and puts an excessive amount of pressure on the abdominal
wall, resulting in the formation or aggravation of diverticula.
On the other hand, diets containing sufficient amount
of fibre end in the production of a softer, bulkier stool, which is easily
moved through the bowel without requiring high pressures.
Current recommendations for fibre intake per day are:
1
At least 25 grams of fibre per day for adult women.
2
At least 30 grams of fibre per day for adult men.
3
28 grams of fibre per day for pregnant women over the
age of eighteen.
4
27-30 grams of fibre per day for women who are
breastfeeding.
Another requirement for the formation of a soft, bulky
stool is an adequate fluid intake. This will ensure that the stool retains
sufficient water to be soft and the bowel is able to produce mucous. The
secretion of mucous allows the stool to pass easily through the bowel rather
than sticking to the wall of the colon.
Drink plenty of fluids each day. Aim for two litres
(eight standard drinking glasses) to ensure sufficient fluid in the body for
bulky, soft stools. Be aware that the term fluid does not just apply to water.
Many items constitute a fluid. These include:
- Water
- Milk
- Juice
- Sports drinks
- Tea
- Coffee
- Soft drinks
- Ice cream
- Custard
- Soup
Previously, many doctors recommended the avoidance of
nuts, popcorn, pumpkin, caraway seeds and sunflower seeds as they believed they
may become stuck in the diverticula and cause infection and inflammation.
These recommendations have since been discontinued as
there is no scientific evidence that these foods have this effect.
Foods high in fibre to include in the diet:
1
Pears
2
Apples
3
Bananas
4
Dried fruit
5
Peas
6
Potatoes with the skin
7
Broccoli
8
Cabbage
9
Spinach
10 Asparagus
11 Squash
12 Carrots
13 Baked
Beans
14 Lentils
15 Chick
peas
16 Kidney
Beans
17 Lima
Beans
18 Wholegrain
or wholemeal bread (Or alternatively high fibre white bread)
19 Whole-wheat
pasta
20 Breakfast
cereals containing barley, wheat or oats
21 Dried
Beans
22 Soy
milk
23 Psyllium
24 Brown
Rice
It may be tempting to include a fibre supplement in
your diet, but try to avoid this if possible because it may cause diarrhoea if
you're not drinking sufficient fluids. Aim to consume all your fibre
requirements by eating a healthy diet.
Dietary
Management of Diverticulitis
The treatment of
diverticulitis is the opposite to that of diverticulosis. During the inflamed
stage of the disease care should be taken to limit fibre in the diet to avoid
further upset or inflammation and to allow the bowel time to rest. In many
cases a fluid diet may be prescribed to ease the burden on the bowel during
times of inflammation.
Decreasing fibre in the diet
during this stage of the disorder aids in limiting the substances passing
through the inflamed section.
The individual is required to
continue on a low fibre diet for a month. If the symptoms have stopped, the
person can resume a high fibre diet.
Previous studies have revealed that in some cases,
those suffering from a colonic disease such as diverticulitis may also suffer
from lactose malabsorption. This means that the body is unable to absorb
lactose from foods or fluids.
Lactose is a form of sugar present in milk and other
dairy products. In the event that the body is unable to absorb lactose, the
individual may suffer from diarrhoea, abdominal pain and abdominal bloating
after eating dairy products.
For this reason it may be
necessary for an individual to select lactose free dairy products while
diverticulitis persists.
Once the condition has been
appropriately treated and subsides, the individual should be able to resume
eating and drinking dairy products. Studies have shown that lactose
malabsorption subsides once diverticulitis has been treated.
Very few studies have been
done in the area of lactose malabsorption resulting from colonic disease, so
current evidence is still slightly controversial. If you are suffering from any
of the aforementioned symptoms of lactose malabsorption contact your doctor.
Tips for optimising your diet
to manage diverticulitis and relieve symptoms
As mentioned in the previous chapter,
adopting a diet low in fibre during the onset and duration of diverticulitis
will aid in managing and alleviating any symptoms that may occur. The following
tips may be useful in decreasing fibre in your diet:
1)
Consume white breads and cereals: During
the process of refining, foods tend to lose much of their fibre content. Breads
and cereals based on white flour are particularly low in fibre and are the
optimal choice for someone suffering from diverticulitis.
2)
Limit, but do not completely eliminate,
the amount of fruit and vegetables you eat. Fibre is mainly obtained from these
types of foods, so it makes sense to limit these in your diet for the duration
of your diverticulitis.
3)
Most of the fibre in fruit and vegetables
is in the skin, so peel your fruit and vegetables before you eat them.
4)
Avoid seeds, nuts, popcorn, and legumes as
these may further irritate the condition.
Foods that are low in fibre include:
· White breads and cereals
· Skinless fruits and vegetables
· Fruit Juice
· Vegetable Juice
· Meat and dairy products
5) In some individuals
it may be necessary to select lactose free dairy products, if lactose
malabsorption is present. Appropriate dairy foods that are low in lactose
include:
1 Soy milk (ensure you select a soy milk fortified with calcium)
2 Most cheeses
3 Lactose free milk
4 Lactose free yoghurt
Summary
This publication is a great starting point
to recognize the symptoms of Diverticulosis and Diverticulitis, but to be
properly diagnosed, you need to visit your doctor.
As you noted in the reading, the treatment
for each phase of the disease is directly opposite, so self diagnosing the
disease could lead to eating the wrong foods and making the disease worse.
As always, check with your doctor first,
before you decide on which path to take.
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