It
is an all too often occurrence in my line of work as a hospital pharmacist that
I see patients coming into the Emergency Room doubled over with abdominal pain.
This isn’t your typical upset-stomach-because-you-ate-something-spicy kind of
pain, but rather a severe give-me-morphine-now type pain. The pain is obviously
bad enough to land someone in their local ER, otherwise they’d just pop some
Tums and call it a night.
What’s
happening here? Why are these patients in so much pain?
While
many different medical conditions can cause abdominal pain diverticulitis is
one of the common culprits in cases like the one described.
What is Diverticular Disease?
Diverticulitis
is a condition contained in a broader range of conditions known as diverticular
disease. Diverticulosis is the other condition in this group. I’ve provided the
definitions of the two terms below to distinguish between them:1
Diverticulosis – The presence of
one or several small, sac-like outpouchings, called diverticula, protruding from
the colonic wall. (To picture this, imagine a long, slender, inflated balloon,
much like the balloons used to make balloon animals. If you squeeze this
inflated balloon just enough you can make a little bubble protrude out of its
side. The formation of this “bubble” would be very similar to the diverticula
formed in the wall of your large intestine. These diverticula are like little
tiny pooches sticking out of the side of your colon.)
Diverticulitis – The acute
inflammation of diverticula associated with fever, pain, and possible infections.
Diverticulosis
occurs first. This condition usually flies under the radar though because most
people never know they have it unless it’s found on a routine colonoscopy.
Diverticulitis comes after, and it’s the reason people end up in the ER with
pain. Ten to twenty-five percent of affected individuals with diverticular
disease will develop symptoms in the form of abdominal pain, bloating,
irregular bowel movements, bleeding, or signs of infection.2,3
Diverticular
disease is common in industrialized nations, affecting up to 60% of the
population over age 60.3 In fact, some of the first researchers to
study the medical condition labeled it a “20th century problem” and
“disease of Western civilization”.2 The United States and Europe have
the highest rates of diverticular disease in the world, while it is rarely
found in developing countries.3,4
What Causes Diverticular Disease and How Does It Develop?
If
you read the research, all the studies agree on one thing—the cause of
diverticular disease isn’t completely known, but a low-fiber diet most likely plays
a significant role.1-5 Based on the high prevalence of this
condition in Western countries, and the rare occurrence in developing countries,
this makes sense. For one, Western cultures eat a diet high in animal-based and
processed foods. Animal foods are completely devoid of fiber. You won’t find
any in meat, dairy, or eggs. Processed foods are also fiber poor. Most of their
fiber is stripped out during the manufacturing process.
In
contrast to Western civilization, populations of developing countries (those
found in Africa, Asia, and parts of South America) often eat a traditional diet
of mostly unrefined plant foods with only small amounts of animal-based and
processed foods. Unrefined plant foods are full of fiber and aid in the
prevention of many chronic diseases.
So
what does fiber have to do with any of this?
The
answer is plenty. Fiber is essential to the formation of healthy bowel movements.
Without it, or with very little of it, constipation can become a chronic
problem leading to hard, compact stools requiring excessive straining to force out of the bowel. [To learn more about constipation read my article, The Anatomy of a Bowel Movement (And How to Cure Constipation)]
Over
time, this constant straining puts pressure on the inside walls of the colon (i.e.
large intestine).6,7 The increase in pressure results in the
formation of the small, sac-like outpouchings (diverticula) we talked about earlier.
These diverticula “bubbles” form at points of weakness in the intestinal wall.
Most diverticula are actually very small—on the order of only a centimeter or
two—but, nonetheless, are still big enough to cause symptoms and complications
in some people.8
The
inflammation, pain, and infections that develop with diverticular
disease are a result of a series of events. Constipation leads to stagnate
fecal matter that finds itself sitting in the diverticula pouches.4 Basically, your poop is “stuck” in the “bubbles”. This in turn triggers
inflammation of the intestinal wall. Pain, fever, bleeding, abscess formation
(pus-filled sacs), and other complications can occur.
In
addition, the balance of the gut bacteria can also be altered due to chronic
constipation and a low-fiber diet. Instead of a colon filled full of “good” (healthy)
bacteria, there is an increase in “bad” (infectious-causing) bacteria that populate
the colon. This can further increase the chances of an infection developing.
Treatment Options for Diverticular Disease
The
best treatment for diverticular disease is prevention, but if you do happen to
develop the condition there are a number of options to look at—the most
important being a lifelong high-fiber diet consisting of unrefined, whole plant
foods.
Treating Acute Diverticulitis
Acute
attacks of diverticulitis will often require bowel rest and possible medical
intervention (antibiotics, workup, drainage of abscesses, surgery, etc.)
depending on the severity. The good news is approximately 75% of patients will
experience pain without inflammation, and of these only 1-2% will require
hospitalization and 0.5% will require surgery.4
Most
patients can be put on bowel rest, which involves abstaining from all solid
foods for 2-3 days before gradually returning to a regular diet (high in fiber
of course). During this time a clear liquid diet (water or other clear
beverages) must be started and adhered to.
Antibiotic
therapy has been the standard of care for years to eradicate any infection occurring
with diverticulitis and are often prescribed preemptively even if no infection
is present. However, recent studies have shown that antibiotic treatment was
not necessary or did not accelerate recovery or prevent future
complications/recurrences of acute uncomplicated diverticulitis in patients.9,10
It’s important to note that both studies referenced here say that further studies
are needed to determine definitive antibiotic treatment in acute
diverticulitis.
With
that being said, if you find yourself in your doctor’s office or local ER
suffering from an acute attack of diverticulitis you are likely to be
prescribed an antibiotic to ward off any possible infection. This is a
reasonable step in my opinion given the alternative—a potentially untreated,
small infection that could develop into a large-scale, serious infection
requiring hospitalization. I will be the first to admit that infectious disease
is one of the areas in modern medicine that we excel in and should be used when the situation calls for it.
Finally,
an absolute must in treating acute diverticulitis is a high-fiber diet if
patients wish to prevent complications and recurrences of disease. It should be
started as soon as the patient can tolerate solid foods again, after their
initial bowel rest.
Treating/Preventing Diverticular Disease
Patients
who experience an acute attack of uncomplicated diverticulitis may have chronic
recurrences of the disease. A 2010 study in the British Journal of Surgery followed several hundred patients with
uncomplicated diverticulitis for up to ten years and found that 18.8% had one
recurrent episode and 4.7% had two or more recurrences of the disease.11
The
goal for any patient with diverticular disease is to not to have any recurrences of disease. So what's the best way to accomplish this?
Fiber. Once again, a high-fiber diet is essential to preventing any recurrent attacks
of diverticular disease. The cause of the disease, as you now know, is a
low-fiber diet. There is a plethora of evidence showing this.
The
Health Professionals Follow-Up Study looked at fiber and food intake and the
risk of developing diverticular disease in 51,529 male health professionals.2
The information gathered from this trial is invaluable. In general, risk of
diverticular disease went down as fruit and vegetable consumption went up.
Beef, lamb, pork, processed meats, cookies, potato/corn chips, French fries,
and white bread were all associated with an increase in diverticular
disease. As an interesting side note in this study, physical activity (running/jogging) was
also shown to reduce the incidence of diverticular disease.
The
above data mirrors a 6-year follow up study of 690,075 women in the UK where
researchers found that as fiber intake increased the risk of diverticular
disease decreased.5 The strongest correlation of disease reduction
was with fruit and cereal fiber consumption. Vegetable fiber also reduced
disease risk.
Another
study evaluated the effects of implementing a high-fiber diet in one hundred
patients diagnosed with acute diverticulitis.3 After 5-7 years on a
high-fiber diet 91% of the patients remained symptom-free.
Four
highly respected professional health organizations responsible for formulating
official guidelines for the prevention and treatment of diverticular disease
also agree with the evidence-based literature on increasing fiber intake in preventing
and treating diverticular disease. They include:3
- American College of Gastroenterology
- European Association for Endoscopic Surgery
- American Society of Colon and Rectal Surgeons
- World Gastroenterology Organization
This
speaks volumes to the importance of adopting dietary changes to prevent or
treat this medical condition. As you know from reading many of my previous
articles, modern medicine is not always the quickest to embrace safe,
conservative, and highly-effective dietary treatment options for the majority
of our chronic diseases in the Western world. I commend and applaud the above
organizations for their recommendations in treating this illness using diet as
a first-line agent.
One more thing I’d like to point out with traditional medical advice regarding diet and
diverticular disease is the notion that persons need to avoid nuts, seeds, corn, and popcorn. Two
studies have refuted this unfounded claim in recent years.8,12 A
2009 article in Clinics in Colon and
Rectal Surgery states, “Without any good evidence, certain foodstuffs
such as nuts, seeds, popcorn, and corn have long been implicated in the development
of diverticulitis and are often advised against by physicians. They were
thought to provoke diverticulitis or diverticular bleeding by causing luminal
trauma. In a large prospective study of men without known diverticular disease,
State et al found that nuts, corn, and popcorn consumption did not increase the
risk of diverticulosis, diverticulitis, or diverticular bleeding.”
Medication Used in Treatment of Chronic Diverticular Disease
A
small number of medications may be used in treating chronic cases of
diverticular disease including anti-inflammatory drugs, antispasmodic drugs,
and antibiotics. I am only going to briefly discuss one—the antibiotic Rifaximin.
Rifaximin
is an antibiotic currently being used in chronic diverticular disease. It is
poorly absorbed into the bloodstream with 97% of the drug being excreted in the
feces unchanged.13 This means most of it stays in the gut, and, therefore,
targets “bad” bacteria that have overgrown the colon. The hope is to reduce
symptoms and complications of diverticular disease.
A
2011 meta-analysis reviewed four trials looking at rifaximin treatment for
chronic diverticular disease.14 Researchers found after one year of
treatment the numbers needed to treat (NNT) for rifaximin were:
1
of 3 people (33.3%) achieved symptom relief
1
of 9 people (11.1%) avoided further complications of diverticular disease
As
with any medication there are possible side effects to consider before taking
rifaximin. The most common side effects include: peripheral edema (15%), nausea
(14.3%), dizziness (12.9%), fatigue (12.1%), ascites (11.4%), diarrhea (10.7%),
headache (10%), muscle spasms (9.3%), itchiness (9.3%), and abdominal pain
(8.6%).15
Summary
Diverticular
disease is a common disease in Western cultures. It is a disease of dietary
causes, namely low fiber intake. Symptoms and complications can lead those
suffering from the condition to seek medical care. Acute attacks of
diverticulitis will require bowel rest and may also need antibiotics to fight
off infection. Surgery for severe cases is rarely needed.
You’re
best bet is to avoid diverticular disease in the first place by adopting a
high-fiber diet consisting of unrefined, whole plant foods. It bears repeating
that animal foods (meat, dairy, and eggs) contain no fiber at all and processed
foods contain very little. These foods should be limited or avoided all together in
order to produce the best possible results in both the prevention and treatment efforts of diverticular disease.
Eat
plants. Get lots of fiber. Live happy. And avoid doctors and pharmacists if at all
possible by adopting a whole foods, plant-based lifestyle. Your body will thank you for many years to come.
If you like what you see here then you'll LOVE our daily Facebook and Twitter posts! Also, don't forget to sign up for Our Free Online Mailing List to get all the latest updates from the Plant-Based Pharmacist!
Check out Dustin Rudolph's book The Empty Medicine Cabinet to start your journey towards better health. This step-by-step guide leads you through many of today's common chronic diseases (heart disease, obesity, diabetes, cancer, and more), giving you the facts on foods versus medications in treating these medical conditions. The book also contains an easy-to-follow guide on how to adopt a whole foods, plant-based diet as a part of an overall lifestyle change, producing the best possible health outcomes for you and your family. Hurry and get your copy today!
by Dustin Rudolph, PharmD Clinical Pharmacist |
Check out Dustin Rudolph's book The Empty Medicine Cabinet to start your journey towards better health. This step-by-step guide leads you through many of today's common chronic diseases (heart disease, obesity, diabetes, cancer, and more), giving you the facts on foods versus medications in treating these medical conditions. The book also contains an easy-to-follow guide on how to adopt a whole foods, plant-based diet as a part of an overall lifestyle change, producing the best possible health outcomes for you and your family. Hurry and get your copy today!
We'd love for you to join us in spreading the good word about plant-based nutrition and lifestyle medicine by telling your family and friends about our website at www.PlantBasedPharmacist.com.
Share and rate this post below or tell us what you think by posting a comment. Thank you again for stopping by and until next time... be happy, be healthy, and live the life you've always dreamed of!
Photo credits: Freedigitalphotos.net
References:
1 Matrana MR,
Margolin DA. Epidemiology and pathophysiology of diverticular disease. Clin
Colon Rectal Surg. 2009 Aug;22(3):141-6.
2 Aldoori W,
Ryan-Harshman M. Preventing diverticular disease. Review of recent evidence on
high-fibre diets. Can Fam Physician. 2002 Oct;48:1632-7.
3 Unlu C.
Daniels L, et al. A systemic review of high-fibre dietary therapy in
diverticular disease. Int J Colorectal Dis. 2012;27:419-427.
4 Boynton W,
Floch M. New strategies for the management of diverticular disease: insights
for the clinician. Ther Adv Gastroenterol. 2013;6(3):205-213.
5 Crowe FL,
Balkwill A, et al. Source of dietary fibre and diverticular disease incidence:
a prospective study of UK women. Gut. 2014;63:1450-1456.
6 Burkitt DP,
Walker AR, Painter NS. Effect of dietary fibre on stools and the transit-times,
and its role in the causation of disease. Lancet. 1972;2:1408-1412.
7 Painter N,
Truelove S, et al. Segmentation and the localization of intraluminal pressure
in the human colon, with special reference to the pathogenesis of colonic
diverticula. Gastroenterology. 1968;54(Suppl):778-780.
8 Beckham H,
Whitlow CB. The Medical and Nonoperative Treatment of Diverticulitis. Clin
Colon Rectal Surg. 2009;22:156-160.
9 Chabok A,
Pahlman L, et al. Randomized clinical trial of antibiotics in acute
uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-9.
10 Hjern F,
Josephson T, et al. Conservative treatment of acute colonic diverticulitis: are
antibiotics always mandatory? Scand J Gastroenterol. 2007;42(1):41-47.
11 Eglinton
T, Nguyen T, et al. Patterns of recurrence in patients with acute
diverticulitis. Br J Surg. 2010 Jun;97(6):952-7.
12 Tarleton
S, DiBaise JK. Low-residue diet in diverticular disease: putting an end to a
myth. Nutr Clin Pract. 2011 Apr;26(2):137-42.
13 Hong KS,
Kim JS. Rifaximin for the treatment of acute infectious diarrhea. Therap Adv
Gastroenterol. 2011 Jul;4(4):227-35.
14 Bianchi M,
Festa V, et al. Meta-analysis: long-term therapy with rifaximin in the
management of uncomplicated diverticular disease. Aliment Pharmacol Ther.
2011;33:902-910.
15 Bass NM, Mullen KD, et al. Rifaximin
treatment in hepatic encephalopathy. N Engl J Med. 2010 Mar;362:1071-1081.
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.