Diverticular disease | Complementary and Alternative Medicine

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Diverticular disease occurs when pouches (diverticula) in the intestine, usually the large intestine or colon, become inflamed.

Diverticulosis is the presence of many diverticula along the intestinal wall. It occurs more commonly in countries such as the U.S. where the diet is generally low in fiber. More than 50% of adults over age 70 have diverticula, and 80% have no symptoms.

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.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 to 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 after a meal on the lower left side of the abdomen
• Either painless rectal bleeding or passing of blood in stool
• Fever
• Nausea
• Vomiting
• Irregular bowel movements, including constipation or diarrhea
• Gas
• Bloating

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 can be life threatening if left untreated.

What Causes It?

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

Who is Most At Risk?

These factors increase the risk for developing diverticular disease:

• Smoking
• Low fiber diet
• Advanced age (more than half of people over age 70 have the condition)
• Obesity
• Male gender, for diverticulitis
• Physical inactivity
• Family history of diverticular disease

The following may contribute as well:

• High fat intake
• Lack of regular physical activity
• Use of non steroidal anti-inflammatory drugs, cortico steroids, and opiate analgesics

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. Your 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:

• Eat a high-fiber (25 to 35 g per day), low-fat diet that contains lots of vegetables. This diet is also beneficial for overall health, and may reduce the risk of heart disease and cancer.
• Avoid red meat.
• Avoid foods that may block the opening of a diverticulum and lead to inflammation, such as high-fat foods.
• Exercise regularly. One study found that men and women who run have a lower risk of diverticular disease than those who do not run.

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. Your provider may recommend starting fiber supplementation at a low dose and gradually increasing the dose. Taking too much fiber too quickly may cause a worsening of symptoms including diarrhea, gas, or bloating.

Drug Therapies

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

Surgical and Other Procedures

If you have repeated episodes of diverticulitis, respond poorly to medical therapy, or have other complications, your provider may recommend removing part of the colon. If you have severe complications, or if your condition worsens within 1 to 2 days of attack, you may need surgery right away.

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 specific dietary recommendations.

Nutrition and Supplements

Eat a diet that is high in fiber (25 to 35 g per day). The following foods may be associated with a lower risk of diverticular disease:

• Cucumber
• Lettuce
• Spinach
• Whole-grain bread

Food is the best source of fiber, but you may also use fiber supplements to increase your fiber intake. Many fiber supplements include insoluble fiber supplements, such as psyllium and glucomannan (3 to 5 g per day of either supplement). Your doctor may also suggest soluble fiber supplements, such as flaxseed 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, 4 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 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, liver disease, or a history of mania or manic episodes.

Omega-3 fatty acids
, such as those found in fish oil, may help fight inflammation. (On the other hand, some omega-6 fatty acids, found in meats and dairy products, tend to increase inflammation.) If you have diverticulitis, eat a diet rich in omega-3 fatty acids, or take a supplement (1,000 mg, 1 to 2 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 unless supervised by your doctor. Omega-3 acids have a blood-thinning effect, and can increase the effect of blood-thinning medications, such as warfarin (Coumadin) and aspirin.

Probiotics
, such as
Lactobacillus acidophilus, Lactobacillus plantarum, Saccharomyces boulardii
, and
bifidobacteria
help maintain the health of the intestines. In one study, people who had diverticulitis were more likely to remain symptom-free after 1 year when they were treated with
Lactobacillus casei
and
mesalazine
. Some probiotics may not be right for people with severely suppressed immune systems.

Herbs

Herbs are a way to strengthen and tone the body’s systems. As with any therapy, you should work with your health care provider before starting treatment. You may use herbs as dried extracts (capsules, powders, or teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 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.
• Slippery elm
  (
  Ulmus fulva
  ) is a demulcent (protects irritated tissues and promotes healing). Take 60 to 320 mg per day. Or mix 1 tsp. powder with water and drink 3 to 4 times a day.
• Cat’s claw
  (
  Uncaria tomentosa
  ) is an anti-inflammatory. DO NOT take cat’s claw if you are pregnant, have an autoimmune disease, or have Leukemia. Cat’s claw can interfere with a variety of medications. Speak with your doctor.
• Wild yam
  (
  Dioscorea villosa
  ). Talk to your doctor before taking wild yam if you have or are at risk of having breast cancer, prostate cancer, or any hormonally-influenced condition. There is some concern that Wild yam may increase clot formation in people with Protein S deficiency, a disorder that predisposes people to form clots.
• Marshmallow
  (
  Althaea officinalis
  ) is a demulcent and emollient. To make tea, steep 2 to 5 g of dried leaf or 5 g dried root in 1 cup boiling water, strain, and cool. Avoid marshmallow if you have diabetes. Marshmallow can interfere with the absorption of many medications and can interact negatively with lithium.
• Chamomile
  (
  Matricaria recutita
  ) 1 to 3 cups of tea per day. To make tea, steep 3 g flower heads in 1 cup boiling water, strain, and cool. Chamomile can have estrogen-like effects, so DO NOT use it if you are pregnant, taking birth control pills, or have a history of hormone-related cancers. High doses may interact with blood-thinning medications. DO NOT use chamomile if you are allergic to Ragweed or related plants.
• Licorice
  (
  Glycyrrhiza glabra
  ) 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, heart failure, kidney disease, or hypokalemia. Look for products that contain only DGL, which means the majority of the blood pressure raising component of licorice has been removed.

Homeopathy

While few studies have examined 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, includes your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a person.

• 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 (or energy) located in various meridians. Acupuncture and Chinese medicine in general may promote gastrointestinal health.

Following Up

If you develop a fever, tenderness in the abdomen, or bleeding from the rectum or in the stool, tell your health care provider right away. You may be hospitalized for a fever higher than 101°F (38.3°C), worsening symptoms, signs of peritonitis, or increased white blood cell count found in laboratory tests.

Prognosis/Possible Complications

Most people with diverticulitis respond well to antibiotics and bowel rest. About one third of people who develop diverticulitis have a second episode, and of this group, half generally have a third attack. About 20% of people 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

If you have experienced bleeding once, you are at high risk for bleeding again.

Supporting Research

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

Comparato G, Fanigliulo, Cavallaro LG, et al. Prevention of complications and symptomatic recurrences in diverticular disease with mesalazine: a 12-month follow-up.
Dig Dis Sci
. 2007;52(11):2934-41.

Crowe FL, Balkwill A, Cairns BJ, et al. Source of dietary fiber and diverticular disease incidence: a prospective study of UK women.
Gut
. 2014;63(9):1450-6.

Feldman.
Sleisenger and Fordtran’s Gastrointestinal and Liver Disease
, 9th ed. Philadelphia, PA: Elsevier Saunders; 2010.

Ferri F. Diverticular Disease.
Ferri’s Clinical Advisor 2015,
1st. ed. St Louis, Mo: Elsevier Mosby; 2014.

Floch M, White J. Management of diverticular disease is changing.
World J Gastroenterol.
2006;12(20):3225-8.

Fox J, Stollman N.
Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease
. 8th ed. Philadelphia, PA: W.B. Saunders; 2006:2613-2617.

Gaertner WB, Kwaan MR, Madoff RD, et al. The evolving role of laparoscopy in colonic diverticular disease: a systemic review.
World J Surg
. 2013;37(3):629-38.

Hjern F, Wolk A, Hakansson N. Obesity, physical inactivity, and colonic diverticular disease requiring hospitalization in women: a prospective cohort study.
Am J Gastroenterol
. 2012;107(2):296-302.

Hjern F, Wolk A, Hakansson N. Smoking and the risk of diverticular disease in women.
Br J Surg
. 2011;98(7):997-1002.

Humes D, Smith J, Spiller R. Colonic Diverticular Disease.
American Family Physicians
. 2011;84(10).

Ibele A, Heise CP. Diverticular disease: update.
Curr Treat Options Gastroenterol
. 2007;10(3):248-56.

Masoomi H, Buchberg B, Nguyen B, Tung V, Stamos MJ, Mills S. Outcomes of laparoscopic versus open colectomy in elective surgery for diverticulitis.
World J Surg
. 2011;35(9):2143-8.

Narula N, Marshall JK. Role of probiotics in management of diverticular disease.
J Gastroenterol Hepatol
. 2010;25(12):1827-30.

Ooi K, Wong Sw. Management of symptomatic colonic diverticular disease.
Med J Aust
. 2009;190(1):37-40.

Rosemar A, Angeras U, Rosengren A. Body mass index and diverticular disease: a 28-year follow-up study in men.
Dis Colon Rectum
. 2008;15(4):450-5.

Salzman H, Lillie D. Diverticular Disease: Diagnosis and Treatment.
American Family Physician
. 2005;72(7):1229-1234.

Sorser SA, Hazan TB, Piper M, Maas LC. Obesity and complicated diverticular disease: is there an association.
South Med J
. 2009;102(4):350-3.

Strate LL, Erichsen R, Baron JA, et al. Heritability and familial aggregation of diverticular disease: a population-based study of twins and siblings.
Gastroenterology
. 2013;144(4):736-742.

Strate LL, Liu YL, Aldoori WH, Syngal S, Giovannucci EL. Obesity increases the risks of diverticulitis and diverticular bleeding.
Gastroenterology
. 2009;136(1):115-122.e1.

Symeonidis N, Psarras K, Lalountas M, et al. Clinical features of colonic diverticular disease.
Tech Coloproctol
. 2011;15(1)S5-8.

Tarleton S, DiBaise JK. Low-residue diet in diverticular disease: putting an end to a myth.
Nutr Clin Pract
. 2011;26(2):137-42.

Tursi A, Joseph RE, Streck P. Expanding applications: the potential usage of 5-aminosalicylic acid in diverticular disease.
Dig Dis Sci
. 2011;56(11):3112-21.

Williams PT. Incident diverticular disease is inversely related to vigorous physical activity.
Med Sci Sports Exerc
. 2009;41(5):1042-7.

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Diverticular Disease and Diverticulitis | Nature’s Best

The colon – or large intestine – is an important part of your digestive system. Not only does it help your body to extract some of the nutrients and water from the food you’ve eaten, but it’s also involved in eliminating undigested waste products from your body, pushing them down into the end of the large bowel (the rectum) and out through the anus.

When small bulges or pockets form in the lining of the colon, they are called diverticula (why this happens in some people, nobody really knows).

According to the NHS, the majority of people with diverticula have no symptoms (i). This is known as diverticulosis. Having diverticula is very common. Around half of all people have them by the time they reach the age of 50, with nearly 70 percent of all people having diverticula by the time they are 80 years old (ii).

But when diverticula are accompanied by symptoms such as intermittent lower abdominal pain and bloating – which happens in 25 percent of people with diverticula (ii) – the condition is called diverticular disease.

Diverticula can also become inflamed and infected when bacteria become trapped inside them. This causes more severe symptoms such as constant cramping pain that usually starts below your belly button and most commonly moves to the lower left-hand side of your abdomen, a high temperature, chills, nausea and diarrhoea. When this happens, the condition is known as diverticulitis.

A small number of people with diverticular disease or diverticulitis can develop complications – though these are fairly uncommon – including the following:

• Abscesses that develop outside the colon are the most common complication of diverticulitis. Some are easily treated with antibiotics, while others may need to be drained under local anaesthetic.

• Peritonitis, caused by an infection that leads to inflammation of the peritoneum (the layer of tissue that lines the inside of the abdomen). This can happen if infected diverticula split. It can be life-threatening, but it’s rare.

• Colon blockage: a total or partial blockage can be caused by scar tissue that forms around inflamed diverticula. A total blockage can lead to peritonitis, while a partial blockage can cause a lot of pain. Again, this is very rare.

• Bleeding from the rectum can also happen in cases of diverticular disease or diverticulitis. Most people affected do not experience pain, and the bleeding usually stops quickly by itself. In a few cases, however, bleeding can be severe, and hospital treatment – including a blood transfusion – is often necessary.

If you think you may have the symptoms of diverticular disease or diverticulitis, see your GP as soon as you can, as it’s important to rule out other conditions that have similar symptoms, including bowel cancer, irritable bowel syndrome (IBS) and pancreatitis.

Diverticular disease and diverticulitis: are you at risk?

Developing diverticula becomes more common as you get older, with being aged 50 or older one of the main risk factors (ii).

However, only around one in four people with diverticula goes on to develop diverticular disease, with 75 per cent of people with diverticular disease having at least one episode of diverticulitis (ii).

Common risk factors

Besides age there are certain things that may increase your risk of developing diverticular disease and diverticulitis, including the following:

• Smoking (if you smoke you’re more likely to develop diverticulitis than someone who doesn’t smoke).

• Having a close relative who has diverticular disease, particularly if they developed it before the age of 50.

• Physical inactivity (if you’re not very active, it also increases your risk of constipation, which itself is a risk factor for developing diverticulitis).

• Being overweight or obese. Discover some simple tips for weight loss in our helpful guide.

• Using non-steroidal anti-inflammatory drugs (NSAIDs), such as the painkiller ibuprofen – though the reason this increases your risk isn’t clear (iii).

Eating a Western diet, with its typically low levels of fibre, has also been associated with the development of diverticular disease and diverticulitis. The NHS acknowledges that, while it isn’t yet known why diverticula develop, they are associated with not eating enough fibre (i).

This may be because the less fibre you eat, the smaller your stools, which means your intestine has to work harder to push them along, causing straining. And over the years, this straining – which also happens with constipation – may lead to diverticula.

The NHS also acknowledges that, while it isn’t yet known why diverticula develop, they are associated with not eating enough fibre.

Diet and diverticular disease/diverticulitis

If not eating enough fibre can promote the development of diverticular disease and diverticulitis, it’s easy to see why eating a high-fibre diet is often recommended to help prevent them – it may also improve your symptoms if you’ve already developed one of the conditions. There is also some evidence that eating lots of fibre and less fat and red meat may help prevent diverticular disease (iv).

Eating more fibre can help to prevent constipation, which is thought to be a factor in the development of diverticula. The latest advice from the government is that everyone should be eating 30g of fibre a day – though according to the NHS the average person eats just 18g a day (v). To eat 30g fibre you need to have the equivalent of five portions of fruit and vegetables, two whole-wheat cereal biscuits, two thick slices of wholemeal bread and a large baked potato with the skin on.

Other examples of high-fibre foods include the following:

• High-fibre breakfast cereals (including porridge)

• Baked beans, lentils and pulses

• Brown rice and wholemeal pasta

• Dried fruits

• Wholemeal crackers and crispbreads

• Nuts

At the same time, try to avoid low-fibre alternatives, such as white or brown bread, white pasta, sugary breakfast cereals, white rice, boiled potatoes without their skins and baked foods made with white flour, such as cream crackers, cakes and biscuits.

Good fibre sources

Fruit is an ideal source of fibre: just one medium pear (unpeeled) contains almost 4g of fibre, while an avocado contains almost 5g. Dried fruits are also high in fibre (three whole dried apricots contain 5g and three whole prunes contain 4.6g – but don’t overdo it, as dried fruits are also high in sugar. Beans, meanwhile, are full of fibre, with half a can of baked beans providing more than 7g.

A medium-sized bowl of All-Bran, however, is one of the best sources, providing almost 10g of fibre. Aim to increase your fibre intake gradually over a few weeks, as loading your digestive system with lots of fibre at the same time could lead to side effects such as bloating and wind.

But if you find it difficult to get the right amount of fibre in your diet, there are fibre supplements you could try (your GP can recommend one that would be suitable).

As well as eating plenty of fibre, experts also recommend drinking plenty of fluids, as this can also help prevent constipation (drink at least six glasses each day).

Staying as active as possible may also help, as exercise is thought to encourage regular bowel movements. Aim for at least 150 minutes of moderate-intensity activity each week, spread throughout the week (half an hour’s exercise five times a week, for example).

Treatments for diverticular disease and diverticulitis

If you don’t have any symptoms but have been diagnosed with diverticula – after having a colonoscopy, for instance – no treatment is necessary (though you will always have diverticula unless they are surgically removed).

Treatments for diverticular disease include taking paracetamol to relieve pain (other painkillers such as aspirin and ibuprofen are not recommended). Over-the-counter remedies such as bulk-forming laxatives may also provide relief if you’re constipated.

Your doctor may advise you to eat a high-fibre diet to manage your symptoms too, though it make take time before you’ll notice any improvements.

Cases of mild diverticulitis can also be easily treated with the following:

• Paracetamol for pain relief

• Antibiotics to treat infection

• A liquid-only diet or low-fibre diet until your symptoms improve

Experts recommend a bland low-fibre diet for mild diverticulitis because it may help prevent further bowel irritation when you’re having a flare-up. However this should only be a short-term measure, and as your symptoms get better you should gradually re-introduce high-fibre foods into your diet.

Natural remedies for Diverticulitis

FOS

Those who struggle to eat the right amount of fibre may benefit from taking a natural fibre supplement, such as inulin and fructo-oligosaccarides (FOS). FOS – found in foods such as asparagus, Jerusalem artichoke, leeks, onions and soya beans – is closely related to inulin, also a soluble fibre, which is extracted from plants including chicory root. Both may help by keeping your bowels regular and by speeding up the movement of waste matter through your digestive system.

However, it’s advisable to stop taking any form of fibre supplements if you’re having an active flare-up of diverticulitis, as during this time your bowel needs to rest.

Glutamine

Another natural supplement that may be useful is glutamine (or L-glutamine), an amino acid derived from glutamic acid. Glutamine is believed to help keep your digestive system healthy – as well as playing a role in the effectiveness of your immune system and other bodily functions – by feeding the cells that line the intestines (enterocytes). As well as keeping the gut lining healthy, many natural health practitioners believe it may reduce inflammation, which in turn may provide relief from diverticulitis symptoms.

Omega-3s

Meanwhile omega-3 fatty acids – including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) derived from fish oils – may also help reduce inflammation, and are thought to be useful in the management of inflammatory conditions (vi). High-strength fish oil supplements may be particularly useful for those who cannot or do not want to eat oily fish such as salmon, pilchards, sardines, herring and mackerel on a regular basis. Meanwhile if you’re a vegetarian or vegan you can still benefit from an omega-3 supplement, thanks to the availability of products that contain the natural triglyceride (TG) form of omega-3, which is sourced from plant organisms called microalgae rather than fish oils.

Peppermint

Finally peppermint oil capsules may provide relief relieving spasms, as it’s thought to help relax the smooth muscle of the intestinal tract (vii). For instance, studies suggest adding peppermint oil to a barium enema makes digestive spasms that such an enema commonly causes less severe (viii). Another study claims peppermint oil may reduce stomach spasms caused by a surgical procedure called an upper endoscopy (ix).

Managing diverticular disease may be difficult, but this article should help get you on the right track. If you’d like more information on a range of common health conditions,  our health library is a good place to start.

References:

1. Available online: https://www.nhs.uk/conditions/diverticular-disease-and-diverticulitis/

2. org/ScholarlyArticle”>

   Available online: https://patient.info/doctor/diverticular-disease

3. Strate LL et al., Use of Aspirin or Nonsteroidal Anti-inflammatory Drugs Increases Risk for Diverticulitis and Diverticular Bleeding. Gastroenterology. 2011 May;140(5):1427-1433.Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3081980/

4. Aldoori. W, Ryan-Harshman. M. Preventing diverticular disease. Review of recent evidence on high-fibre diets. Can Fam Physician. Circulation. 2002;48:1632-1637.

5. Available online: https://www.nhs.uk/live-well/eat-well/how-to-get-more-fibre-into-your-diet/

6. org/ScholarlyArticle”>

   Simopoulos. AP. Omega-3 fatty acids in inflammation and autoimmune disease. J AM Coll Nutr. 2002 Dec;21(6):495-505.

7. Chumpitazi. BP, Keams. G, Shulman. RG. The physiologic effects and safety of Peppermint Oil and its efficacy in irritable bowel syndrome and other functional disorders. Aliment Pharmacol Ther. 2018 Mar;47(6)110:738-752.Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814329/

8. Sparks. MJ, O’Sullivan. P, Herrington. AA, et al. Does peppermint oil relieve spasm during barium enema? Br J Radiol. 1995;68:841-843.

9. Asao. T, Kuwano. H, Ide. M, et al. Spasmolytic effect of peppermint oil in barium during double-contrast barium enema compared with Buscopan. Clin Radiol. 2003;58:301-305.

10. Hiki. N, Kurosaka. H, Tatsutomi. Y, et al. Peppermint oil reduces gastric spasm during upper endoscopy: a randomized, double-blind, double-dummy controlled trial. Gastrointest Endosc. 2003 ;57:475-482.

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Disclaimer: The information presented by Nature’s Best is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. Self-treatment is not recommended for life-threatening conditions that require medical treatment under a doctor’s care. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.

Christine

Christine Morgan has been a freelance health and wellbeing journalist for almost 20 years, having written for numerous publications including the Daily Mirror, S Magazine, Top Sante, Healthy, Woman & Home, Zest, Allergy, Healthy Times and Pregnancy & Birth; she has also edited several titles such as Women’ Health, Shine’s Real Health & Beauty and All About Health.

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Prevention of complications of diverticular disease of the colon in outpatient practice

DBTC — diverticular disease of the colon

CI – confidence interval

Gastrointestinal tract

CT – computed tomography

OD – acute diverticulitis

RR – relative risk

DM – diabetes mellitus

CO – mucous membrane

CRP – C-reactive protein

FC – fecal calprotectin

At the stage of primary care, abdominal pain syndrome remains a difficult task for the therapist and gastroenterologist. To make the right decision on the choice of patient management tactics, specific knowledge is needed about the prevalence and etiology of abdominal pain syndrome, potential risks of developing diseases that cause pain, and the chances of recovery or factors of an undesirable course of the disease.

As a result of a systematic review of 14 studies, it was found that among all consultations at the stage of primary care, abdominal pain syndrome as a reason for seeking medical help is 2.8%. The most common etiological causes are gastroenteritis (7.2-18.7%) and irritable bowel syndrome (2.6-13.2%). It should be taken into account that 5.3% of patients have urological causes of abdominal pain. In about 1 in 10 patients, abdominal pain necessitates emergency surgery. Diverticulitis was detected in 3% of patients with abdominal pain, ranking third in frequency among diseases of the gastrointestinal tract (GIT) after gastritis (5.2%) and pathology of the biliary tract and pancreas (4%) and ahead of appendicitis (1. 9%) and neoplastic processes (1%) [1].

Often, the diagnosis of diverticular disease of the colon (DBTC) is first made after the development of severe complications. DBTC is a polyetiological disease that requires a differentiated approach to the correction of both systemic causes and clinical manifestations and complications [2]. The results of studies by domestic and foreign authors show that in the general structure of intestinal diseases, diverticula of the colon make up 16-20%. The frequency of detection of diverticula and their number increase with age: among people under 40 years old, about 10%, and at the age of 80 years – in 66 %. There are no gender differences in the incidence of DBTC [3, 4]. It should be taken into account that the frequency of development of complications of DBT also increases with age: at the age of 65-69years, the number of complicated forms of DBTC is 238 per 100,000 patients, and in the group of patients older than 85 years – 631 per 100,000 [5]. Since there is no unified classification of diverticular disease yet, in preparing the review, we were guided by the Clinical Guidelines for the Diagnosis and Treatment of Adult Patients with DBT, published in 2013 by the All-Russian public organization “Association of Coloproctologists of Russia”. Of the complicated forms of DBTC, this review considers acute diverticulitis (OD) and the recurrent course of chronic diverticulitis. We did not touch upon the issues of prevention of life-threatening conditions requiring urgent surgical intervention (peritonitis, diverticulum perforation, bleeding).

One of the most common complications of BTK is OD, which represents a significant burden on national health systems in terms of both direct and indirect costs. The problem of preventing colonic diverticulitis and its recurrence is relevant, since over the past 25 years the number of hospitalizations due to this disease has increased significantly. This is evidenced by the data of Norwegian scientists who conducted a retrospective analysis of all cases of treated OD in the period 1988-2012 in one of the hospitals in the center of Norway. Poisson regression analysis showed a 2.8-fold increase in hospitalizations (95% CI 2.2 to 3.5) over the last 25 years. The number of hospitalizations increased from 17.9 (95% CI 14.1 to 22.3)/100,000 between 1988 and 1992. to 51.1 (95% CI 44.8 to 58.0)/100,000 in 2008-2012 The overall incidence was 29.4 (95% CI 27.1 to 31.7) per 100,000 person-years. Its growth by 2.6 times was noted (at 95% CI from 1.96 to 3.34) [6]. In the United States, statistics show 75 hospitalizations per year for ML per 100,000 population. Recent reports show a 26% increase in hospital admissions over the previous 7-year period [7].

Uncomplicated OD in the recent past has traditionally served as an indication for inpatient treatment with functional bowel rest, intravenous antibiotics and detoxification therapy. In recent years, there has been an increase in the number of publications trying to determine whether it is possible to treat such patients on an outpatient basis with an earlier transition to enteral nutrition and oral antibiotics. J. Jackson and T. Hammond [8] presented a systematic review of the Medline, Embase, and Cochrane Library databases to evaluate the safety and efficacy of this outpatient approach. In all studies 403 (97%) of 415 participants with uncomplicated OD were successfully treated on an outpatient basis. Savings ranged from 35.0 to 83%. Thus, the current data suggest that a more progressive outpatient approach based on a large number of cases of successful treatment of patients with uncomplicated OD is warranted. Outpatient treatment is recognized as safe and effective in 90% of patients with uncomplicated diverticulitis and other reputable researchers [9].

For planning the budgets of health insurance companies and healthcare systems in different countries, not only the incidence rate is important, but also the prognosis of patients with various nosologies, in particular diverticulitis.

According to a systematic review by A. Morris et al. [10], the course of the disease and the prognosis of uncomplicated diverticulosis in most patients are benign. For example, in a cohort study of 3165 patients hospitalized for OD with a median follow-up of 8.9 years, only 13.3% relapsed after the first attack of diverticulitis, and another 3.9% of patients had a second relapse. In contrast to the previously existing opinion, it was found that the risk of septic peritonitis with each repeated exacerbation decreases, not increases. The results of the study show that from 20 to 35% of patients treated conservatively suffer from chronic abdominal pain compared with 5-25% of patients treated surgically [10]. The frequency of relapses after drug therapy for an attack of OD varies from 13 to 36% [7].

A study conducted at the Levanger Hospital between 1988 and 2012 assessed the short and long term disease outlook, relative survival and causes of death in patients hospitalized for O.D. The median follow-up was 6.95 years (range 0.28–24.66 years). The total number of hospitalizations for OD over 25 years reached 851 per 650 patients. The most common was uncomplicated diverticulitis (738 cases). Abscess formation and purulent peritonitis due to perforation were found in 44 and 47 patients, respectively, perforation and fecal peritonitis – in 9, intestinal obstruction – in 13. During the long-term follow-up, 219 people died, 431 were alive at the end of the study. After the first episode of diverticulitis, the 100-day relative survival rate of patients with uncomplicated diverticulitis was 97% (with 95% CI from 95 to 99%), in patients with abscess formation – 79% (with 95% from 62 to 89%), in patients with purulent peritonitis – 84% (at 95% from 69 to 92%), with fecal peritonitis – 44% (at 95% from 10 to 74%), with intestinal obstruction – 80% (at 95% from 38 to 96%). In the 609 patients who survived the first 100 days, the estimated 5-year relative survival was 96% (95% CI 92 to 100) and 10-year survival was 91% (95% CI 84 to 97). At the same time, there were no significant differences in the long-term relative survival among patients with various clinical forms of diverticulitis. The authors associate the prognosis of the disease with the general condition of the patient according to the ASA classification (American Society of Anaesthesiologists classification of Physical Health) at the time of hospitalization. All patients whose condition severity was 4 points or more on the ASA scale died within 2 years [11].

Frequency and risk factors for diverticulitis and its recurrence. Among the factors predisposing to the development and recurrence of OD are obesity [12-15], smoking, insufficient intake of dietary fiber, lack of physical activity [16] and the use of drugs such as acetylsalicylic acid and non-steroidal anti-inflammatory drugs [17].

In another systematic review, the pathophysiology of diverticulitis was associated with altered intestinal contractility, increased intraluminal pressure, and impaired quantitative and qualitative composition of the colonic microbiota. In the same review, covering 186 articles, several studies demonstrated the histological similarity of diverticulitis with inflammatory bowel disease and irritable bowel syndrome, but focused on comparison, rather than on identifying causal relationships [10].

Against the backdrop of an epidemic increase in the incidence of diabetes mellitus (DM) all over the world, the question of the influence of DM on the course of complicated forms of DBTC becomes relevant. An epidemiological study with III level of evidence presents the results of a comparison of 2 groups of patients: with and without SD. 1019 cases of hospitalization were retrospectively analyzed according to the severity of the disease (using the Hinchey scale and Ambrosetti computed tomography gradation). At the same time, lethality, length of stay in the hospital, the need for surgery, postoperative complications and the frequency of repeated hospitalizations were studied. It was found that in the group of patients with DM the course of OD is more severe than in the group of patients without DM (3 or 4 points on the Hinchey scale in 12.2 and 9.2% respectively; p <0.001), more comorbidities and more patients in older age groups. But at the same time, there were no significant differences in the ineffectiveness of conservative therapy (2. 2% of patients with DM compared with 2.5% of patients without DM; p = 1.000), in the number of readmissions or mortality [18].

Based on a retrospective analysis of the clinical and radiological features of the course of the disease in 469 patients successfully treated conservatively after the first attack of uncomplicated diverticulitis between 2002 and 2012, as a result of one- and multivariate analysis, multiple diverticula were classified as risk factors for recurrence (relative risk – RR 2 .62 at 95% CI 1.56 to 4.40) and localized intraperitoneal diverticulitis (RR 3.73; 95% CI 2.13 to 6.52). In the case when these two factors were combined, the risk of recurrence increased to 54.5%, and the risk of the need for surgery – up to 15.2%. There were no differences between right- and left-sided variants of DBTC [19].

Laboratory and instrumental predictors of complicated course and recurrence of diverticulitis. A. Kechagias et al. [20] conducted a retrospective evaluation of the results of examination and treatment of 182 patients with diverticulitis. The patients were divided into the following groups: 158 (87%) with a mild course of the disease, in which conservative treatment was successful, and 24 (13%) with a severe course, which required percutaneous drainage of the abscess and / or surgical intervention. At the level of C-reactive protein (CRP) less than 170 mg/l, there was a high probability of a mild course of diverticulitis and the effectiveness of conservative therapy. Patients with CRP above 170 mg/l were at greater risk of undergoing surgery or at least percutaneous intervention. As a result of logistic regression analysis, the authors came to the conclusion that CRP levels of 170 mg/l and higher (sensitivity 87.5%, specificity 91.1%, area under the characteristic curve 0.942; p <0.00001) [20], and this should be taken into account by outpatient doctors when examining patients.

Another work is devoted to the study of the microbiota in patients with OD to assess the prognostic significance of the diagnosis of dysbiosis. The work compared the results of a microbiological study of feces of 31 patients with a left-sided variant of diverticular disease with computed tomographic signs of uncomplicated diverticulitis and 25 subjects of the control group. The polymerase chain reaction (PCR) method was used in DNA isolates from basic stool samples. Differences in the abundance and diversity of bacterial strains were assessed by the Shannon index: the higher the index, the greater the diversity of microorganism species. Discriminant analysis of cross-validation of partial least squares was used to develop a predictive model in the diagnosis of diverticulitis. The diagnostic accuracy of the regression model in it was 84%. The authors concluded that there is a greater variability of the microbiota in patients with OD compared with controls, and the definition of clusters Proteobacteria was proposed as a new diagnostic method for diverticulitis [21].

In a prospective cohort study of fecal calprotectin (FC), the results obtained allowed the authors to suggest an association between abnormal FC levels and recurrence of diverticulitis and recommend an elevated FC level as a predictor of an unfavorable course of the disease [22].

In a review article by P. Ambrosetti [23], the severity of diverticulitis according to computed tomography (CT) is indicated as a prognostic factor for a complicated course of the disease. The gradation of the severity of the course of diverticulitis according to CT data helps to predict an unfavorable outcome after the treatment of the first episode.

Diagnosis of OD is based mainly on clinical, laboratory and radiological (CT) signs. Colonoscopy after an episode of diverticulitis is not necessary for all patients. Colonoscopy should be prescribed only for patients with symptoms of “anxiety” and identified risk factors for the development of colorectal cancer [24].

Non-drug methods for the prevention of OD and recurrence of chronic diverticulitis. In any case, the treatment of patients with various forms of DBTC should begin with recommendations for lifestyle changes. It suggests an increase in the amount of dietary fiber in the patient’s diet The theory that active therapy with a high-fiber diet can prevent the development of diverticulosis and / or its complications is supported by the only large prospective controlled study of the Health Professionals Follow-up Study, which followed 47,678 Americans [25]. Over a 6-year period, a significant inverse relationship was found between the intake of insoluble fiber (especially fruits and vegetables, i.e. cellulose) and the risk of developing symptomatic diverticular disease (RR 0.56 at 95% CI 0.44 to 0.91). Recently, there have been reports that diets enriched with dietary fiber do not differ much from placebo, but all these studies have level C evidence. Therefore, recommendations for adequate intake of dietary fiber are still relevant. The recommended norm of dietary fiber is 25-32 g per day, which corresponds to approximately 400-450 g of vegetables and fruits [26, 27]. To prevent excessive gas formation in the intestines and increase motivation, it is necessary to focus the patient’s attention on a gradual increase in the daily intake of vegetables and fruits (over several weeks). Heat treatment of products also contributes to the reduction of gas formation. Another necessary condition is sufficient physical activity: in many guidelines it is defined as a daily 30-minute walk at a brisk pace [28].

Already at the stage of dietary recommendations, bran or psyllium can be prescribed to the patient to increase the amount of dietary fiber in the diet. The amount of bran increases from 1-2 teaspoons to 6-8 tablespoons within 2-4 weeks. In addition, bran and psyllium can serve as an example of the application of the principle of multipurpose monotherapy, i.e. the ability to use the systemic effects of one drug to simultaneously correct the impaired functions of several organs or systems. A beneficial effect of psyllium on weight loss has been established [29] and hypercholesterolemia [30].

Anti-relapse treatment of diverticulitis. Salicylates. A meta-analysis of 6 randomized controlled trials (a total of 818 patients) evaluated the efficacy of mesalazine in diverticular disease: 3 studies were conducted in patients with uncomplicated diverticulitis and 3 studies in patients with symptomatic diverticular disease. The authors concluded that mesalazine therapy leads to better treatment outcomes than therapy in the control group. At the same time, the appointment of mesalazine on a permanent basis (daily intake), in contrast to cyclic administration (10 days of each month for 24 months), had a more pronounced anti-relapse effect [31]. The effectiveness of salicylates is due to a wide range of anti-inflammatory effects [32]. Although 5-aminosalicylic acid preparations have proven effective in the treatment of symptomatic uncomplicated DBT, their role in the prevention of recurrence of diverticulitis is still under discussion [33]. Recently published results from the phase III PREVENT1 and PREVENT2 trials evaluated the efficacy and safety of multimatrix mesalazine versus placebo in preventing recurrent diverticulitis in 590 (PREVENT1) and in 592 (PREVENT2) adult patients with one episode of OD or more in the previous 24 months, eliminated without surgery. Patients received mesalazine (1.2, 2.4, or 4.8 g) or placebo once daily for 104 weeks. The main evaluation criterion is the number of relapses (in percent) in patients by the 104th week. Diverticulitis recurrence is defined as a surgical intervention at any stage of the study or the presence of radiological (CT) signs of diverticulitis – thickening of the intestinal wall (more than 5 mm) and / or adipose tissue soldered to the diverticulum. In some patients, signs of relapse were abdominal pain and leukocytosis. No new side effects have been identified with mesalazine.

The authors concluded that mesalazine is not superior to placebo in the prevention of recurrent diverticulitis and cannot be recommended as the drug of choice for this pathology [34].

Antibiotics. Non-absorbable antibiotics should be preferred when prescribing antibiotics to prevent complications of DBTC. Rifaximin has the widest antibacterial spectrum. The possibilities of rifaximin were evaluated in a multicenter, randomized, open, controlled trial in 165 patients with a recent episode of colonic diverticulitis who were in remission at the time of enrollment in the study. Patients received a high-fiber diet (3. 5 g) with or without the addition of rifaximin at a dose of 400 mg for 1 week of each month for 12 months. The main evaluation criterion is the recurrence of diverticulitis, including episodes of acute symptoms with or without complications. A multivariate logistic regression analysis was carried out and the Cox coefficient was determined (the Cox proportional hazards model is the prediction of the risk of an event occurring for the object under consideration and the assessment of the influence of predetermined independent variables on this risk). Relapses were noted in 10.4% of patients treated with rifaximin and dietary fiber supplements versus 19.3% of patients who received only dietary fiber. Logistic analysis taking into account gender, age, duration of the disease, time from the last episode of exacerbation and localization of diverticulitis showed a significant treatment effect (odds ratio 3.20 with 95% CI from 1.16 to 8.82; p \u003d 0.025). Both treatments are considered safe. Thus, prophylactic administration of rifaximin to reduce the risk of diverticulitis recurrence was recognized by the authors as effective [35].

Similar results on the effectiveness of rifaximin in reducing the risk or progression of complications of OD were obtained in another previously conducted small (36 patients) study [36]. However, the anti-relapse effect of rifaximin was less than that of mesalazine [37].

Probiotics. The intestine is well known as the largest human lymphoepithelial organ, producing more antibodies (mainly secretory IgA) daily than all other lymphoid tissues. According to L. Dughera et al. [38], the main cause of OD is the abnormal accumulation of fecal bacteria in the lumen of the diverticulum and their adhesion to the intestinal mucosa (CO), leading to an imbalance between the normal microbiota and pathogenic species: gram-negative Enterobacteriaceae mainly Escherichia coli and Proteus spp. Their study (83 patients) evaluated the efficacy of an oral immunostimulant, a highly purified polymicrobial lysate, in preventing recurrent episodes of diverticulitis. In the group of patients who took a highly purified polymicrobial lysate, compared with the placebo group, an improvement in symptoms and a decrease in the number of episodes of diverticulitis recurrence were revealed. The authors of the study explained the effectiveness of the drug by direct stimulation of the IgA-mediated protection of colonic CO2 [39].

However, in a further comparative study of the effectiveness of various groups of drugs, in particular polymicrobial lysate in the prevention of diverticulitis relapses, there were not enough arguments to recommend this drug for immunostimulation from the standpoint of evidence-based medicine [40].

According to some researchers, the combination of mesalazine and probiotics may reduce the number of recurrences of diverticulitis. However, further randomized controlled trials are needed to test this [41].

The use of probiotics may be promising, but further robust studies are needed to confirm preliminary results [33].

Butyrate. Interest in butyric acid preparations is associated with the anti-inflammatory and regenerative effect of butyrate in relation to colonic mucosa. In the work of L. Krokowicz et al. [41] from the University of Poznań studied the role of microencapsulated butyrate in patients with diverticulosis, its possible potential for reducing the frequency of episodes and preventing diverticulitis. Within 12 months in the study group, the number of episodes of diverticulitis was 2 (6.67%) versus 7 (31.8%; p = 0.0425) in the control group. Compared with the placebo group, the number of cases of ultrasound confirmation of diverticulitis was statistically significantly less (1 vs 5; p = 0.0229). Similar results were obtained with CT colonography. The number of patients who noted an improvement in well-being and an increase in the quality of life in the group receiving butyrate was statistically significantly higher in the treatment group (55.67% vs. 22.73%; p = 0. 0143). During the entire observation period (12 months), not a single case of side effects of microencapsulated butyrate was noted. The authors concluded that butyric acid supplementation in patients with asymptomatic diverticulosis significantly reduces the number of episodes of diverticulitis and the number of appropriate instrumental tests required to confirm diverticulitis ( p = 0.0229). After 12 months of taking butyrate, the majority of patients felt better ( p = 0.0143). Accordingly, butyrate can be considered as an option to prevent the progression of clinical symptoms of diverticulosis.

Thus, in outpatient practice, the approach to the prevention of complications of DBT should be comprehensive and include recommendations for changing lifestyle and nutrition with the subsequent prescription of pharmacological drugs. Among the main groups of drugs, non-absorbable antibiotics, 5-aminosalicylic acid preparations, and protected forms of butyric acid should be considered. The issue of prescribing probiotics as a prophylactic has not been finally resolved.

No conflict of interest.

Diverticulosis of the colon – Treatment in the multidisciplinary family clinic “K medicine”

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Diseases

Colon diverticulosis

Colon diverticulosis – inflammation and protrusion of the walls of the large intestine.

• Reasons
• Main features of
• Diagnostics
• How to treat
• What is dangerous
• Prevention

Causes:

• weakness of the intestinal wall, progressive with age;
• irrational nutrition;
• disorder of the digestive system;
• genetic predisposition;
• injury;
• increased pressure in the intestines with constipation;
• violation of the motor function of the muscular wall of the colon;
• pregnancy and childbirth.

Key Features

As a rule, this disease is detected by chance during an examination of the intestine, since it does not have specific symptoms. Still, some symptoms can be named:

• severe pain in the abdomen;
• constipation;
• stool disorders;
• feeling of weakness;
• admixture of blood in the stool;
• diarrhea;
• pain on palpation of the abdomen.

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Diagnostics

Diagnosis of diverticulosis includes the following steps:

• consultation with a gastroenterologist;
• biochemical and general blood test;
• analysis of feces and urine;
• ultrasound examination of the abdominal organs;
• x-rays to rule out intestinal obstruction and evaluate bowel folds;
• irrigoscopy: X-ray contrast study of the structure of the walls of the colon;
• colonoscopy: examination of the colonic mucosa from the anal canal to the intestinal valve using a video endoscope.

How to treat a disease

Treatment of this disease may include the use of painkillers, antispasmodic and antibacterial drugs, taking laxatives. A certain diet and diet are prescribed.

Why diverticulosis is dangerous

The most common complications are intestinal bleeding, purulent inflammation in the abdominal cavity, which is formed due to thinning of the wall, intestinal obstruction. In the absence of timely and comprehensive treatment, the disease leads to the development of malignant neoplasms.

Prophylaxis

To rule out colonic diverticulosis, you should:

• Eat only healthy foods that include plenty of high-fiber foods;
• refuse food additives;
• to live an active lifestyle;
• regularly undergo examinations by medical specialists.

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