Diverticular disease

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.

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 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.

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 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.